Invention Disclosure

Docket No.

Descriptive Title:

Assigned To:

Related Invention Disclosures:

Inventor: Business Unit:		Co-inventor:
Full Name – No Initials Citizenship		Full Name – No Initials Citizenship
Home Address, Street		Home Address, Street
City, County, State, Zip	Company	City, County, State, Zip	Company
Telephone Extension		Telephone Extension
Signature – Full Name – No Initials Date		Signature – Full Name – No Initials Date

Co-inventor: Business Unit:		Co-inventor:
Full Name – No Initials Citizenship		Full Name – No Initials Citizenship
Home Address, Street		Home Address, Street
City, County, State, Zip	Company	City, County, State, Zip	Company
Telephone Extension		Telephone Extension
Signature – Full Name – No Initials Date		Signature – Full Name – No Initials Date

Witnessed and understood by:

Full Name – No Initials

Signature – Full Name – No Initials Date

Please complete the following:

When did you conceive this invention (date)?
Where is the invention recorded?
Have you discussed this invention with any person outside of your company?		Y	or	N
If Yes, who?	when?

Has a written description of your invention been distributed outside of your comany?		Y	or	N
If Yes, who?	when?
where?
If No, is such publication or distribution planned?		Y	or	N
when?	where?

Is the invention in any device or system that you intend to demonstrate or sell?		Y	or	N	x
If Yes, where?	when?
Is the invention the result of any work or cooperative activity with a university?		Y	or	N
If Yes, where?	when?
Does the invention use or require information or material that might be proprietary to another company or organization?		Y	or	N
If Yes, please describe

Attach results of any testing that has been done.

Inventor Checklist

What is the problem that you are trying to solve:

Is this a new idea for existing or new business:

What is the advantage for a client:

What do you feel is new compared to what is known right now?

Summary of Invention

Detailed Description of the Invention (use extra sheets, if required)