IAC Confidential Innovation Registration and Disclosure Document

INNOVATION ASSESSMENT CENTERCONFIDENTIALINNOVATION REGISTRATIONAND DISCLOSUREAGREEMENTA service of the Washington State UniversityEDA UNIVERSITY CENTERImplementation funding made available by the State of WashingtonAdministrative OfficesCollege of BusinessWashington State UniversityMail or e-mail completed forms to:INNOVATION ASSESSMENT CENTERCollege of Business440 Todd HallP.O. Box 644750Pullman, WA 99164-4750CB.iac@wsu.edu509-335-7876http://www.business.wsu.edu/organizations/iac/Pages/index.aspxRevised October, 2010© Copyright 2010 by Washington State University

3. Invention and Intellectual Protection Information3A). DESCRIPTION OF INVENTION. Describe your invention in detail and explain how your researchfindings impact this field in a new way. (Use additional sheets as needed, and attach any available reports,grant applications, theses, dissertations, drawings, figures, tables, photos, etc.)3B). LEGAL PROTECTION. Currently I have the following forms of protection for this invention:___ No Protection___ Notarized records of invention___ Copyright. Number:Issue Date: _______________________________ Preliminary patent search (Date:_____________________) Copy of results enclosed?___ Disclosure Document with U. S. Patent Office. Date: _______________________________ Patent applicationDate: _______________________________ PatentNumber: ________________ Issue Date: ____________________________Copy of patent enclosed? __________________3C). KEY SEARCH WORDS (to be used for patent and/or literature searches).CONFIDENTIAL: This Invention Registration and Disclosure may contain proprietary information and may not bedisclosed to anyone not bound under the terms of a written confidentiality agreement.IAC Invention Registration & Disclosure Page 4 of 10 Revised 10-20-10

3D). NOTARY. It is suggested, but not required, that you have this description notarized if you have no otherform of protection for your invention. This establishes the date of conception of your idea. A DETAILEDDESCRIPTION IS NECESSARY.State of:County of:On this ____________ day of ________, 20____, before me ______________________________,Notary Public, personally appeared _____________________________________ known to me (orproved to me on the oath of ______________________________) to be the person whose name issubscribed to the within instrument, and acknowledged that he (she or they) executed the same.Witness my hand and official seal:Notary Public in and for theState of:County of:My Commission expires:CONFIDENTIAL: This Invention Registration and Disclosure may contain proprietary information and may not bedisclosed to anyone not bound under the terms of a written confidentiality agreement.IAC Invention Registration & Disclosure Page 5 of 10 Revised 10-20-10

4) PUBLICATION AND PUBLIC DISCLOSURE. Public disclosure of your invention prior to the filing of apatent application may affect patent options. If prior disclosure was made under the terms of a writtenconfidentiality agreement, please so note that fact and attach a photocopy of the agreement to yourInvention Disclosure form.Date this inventionwas first conceived:Please describe how and where this is documented:Prior Publications and Presentations:Date(s) publishedand /orpresented:List all printed and online publications of this invention (e.g. scientific papers, websites,theses, etc.)List all public disclosures given outside your laboratory (e.g. lecture, conferences, postersessions, invited speaker, discussions with industry, etc.)Upcoming Publications and Presentations:Date(s) ofscheduledpublicationsand/orpresentations:Details of intended publications and presentations (including discussions with industry).CONFIDENTIAL: This Invention Registration and Disclosure may contain proprietary information and may not bedisclosed to anyone not bound under the terms of a written confidentiality agreement.IAC Invention Registration & Disclosure Page 6 of 10 Revised 10-20-10

5. DEVELOPMENT STATUS. Describe the current development status of your invention oridea.I currently have:Sketches and drawings (helpful for evaluation)___ Idea only___ Rough sketches or diagrams___ Finished working drawings___ Enclosed___ EnclosedPrototype of product (if prototype exists, please enclose 3 sets of photographs; DO NOTSEND PROTOTYPE UNLESS REQUESTED)___ No prototype___ Design model___ Functional model___ Market ready modelDesign modifications: I have considered these design changes:6. MARKET TESTING AND COMMERCIAL POTENTIAL.6A). MATERIALS AND BIOLOGICAL TESTING. Were any biological, chemical, or physicalmaterials that were obtained from others used in the creation of this invention? If you obtainedmaterials under the terms of a Materials Transfer Agreement, please so note that fact and attach aphotocopy of the agreement to your Invention Disclosure form.If yes, please explain the circumstances.YESNO6B). PRODUCT TESTING.Does the product work as intended? Yes ____Estimated life span before failure:Testing conducted by:No ____CONFIDENTIAL: This Invention Registration and Disclosure may contain proprietary information and may not bedisclosed to anyone not bound under the terms of a written confidentiality agreement.IAC Invention Registration & Disclosure Page 7 of 10 Revised 10-20-10

6C). DISCUSSED IDEA WITH OTHERS. I have shown or discussed my idea/invention with others:___ Relatives ___Family ___ Others (Specify):Positive comments:Negative comments:6D). COMPETITORS AND COMPETING TECHNOLOGIES. List existing products or processesthat perform a similar function.6E). COMPETITIVE ADVANTAGE. Describe why your invention is better than existing products orprocesses. Number these in order of importance.6F). MARKETING EFFORTS. Describe any previous attempts that have been made to sell yourproduct. Include dates, locations, results and why efforts were discontinued.6G). PREVIOUS AGREEMENTS OR COMPANY INTEREST. List previous agreements to use yourproduct and/or any companies that have expressed an interest in your product.6H). CUSTOMER ACCEPTANCE. I have planned for or developed the following:___ Instructions for proper use___ Product visual appearance for customer appeal___ Packaging design: ___ for display ___ for protection ___ for shipping ___ for customer appeal___ With professional assistance; supply details:___ On my own___ None of the aboveCONFIDENTIAL: This Invention Registration and Disclosure may contain proprietary information and may not bedisclosed to anyone not bound under the terms of a written confidentiality agreement.IAC Invention Registration & Disclosure Page 8 of 10 Revised 10-20-10

7. COST AND PRICING INFORMATION7A). COSTS. Estimate manufacturing costs, dates, and sources.Materials (per unit): _________________ Date: __________________ Source: ________________Labor (per unit): ____________________ Date: __________________ Source: ________________Equipment (dies, molds, etc.): ____________________ Date: ___________ Source: ____________7B) PRODUCT PRICING. Indicate different pricing levels, if applicable, per unit.Estimated price to wholesaler or distributor: $ _______________Estimated price to retailer:$ _______________Estimated price to end customer:$ _______________8. FINANCIAL AND OTHER SUPPORT8A) FINANCIAL SUPPORT. The federal government requires that inventions, whether patentable or not, bereported to the funding agency that provided financial support for the research that led to the creation and/orreduction to practice of the invention. If any part of the invention was developed with financial support from afederal, state, or local agency and/or with financial support from an industry sponsor, please provide thesource of support and contract numbers.PercentAgency or Sponsor Contribution*Grant or Contract Number*Please note that the sum of contributions must total 100%.8B) Was support for the creation and/or implementation of your invention obtained from sources notlisted above? If so, please identify those sources and describe the circumstances involved:CONFIDENTIAL: This Invention Registration and Disclosure may contain proprietary information and may not bedisclosed to anyone not bound under the terms of a written confidentiality agreement.IAC Invention Registration & Disclosure Page 9 of 10 Revised 10-20-10

9) NAMES AND SIGNATURES OF INVENTOR(S). Please list the names of all individuals whocontributed to the conception and/or reduction to practice of the invention. By signing below, all universityoriginators/inventors agree to assign, and hereby assign, all right, title and interest to this intellectual property toWashington State University (WSU) and agree to execute all documents as requested, assigning to WSU theirrights in any patent application or other intellectual property protection filed on this invention, and to cooperatewith WSU in the protection of this intellectual property. By signing below, the originators/inventors confirm thatprior to the execution of this disclosure, they have not granted the right or license to make, use, or sell thedisclosed intellectual property to anyone except to WSU, nor have they otherwise encumbered their rights, title,and interest in the disclosed intellectual property, nor will they execute any instrument in conflict with thisagreement.Name Signature Date CitizenshipUSA10) WITNESS. I have read and understand the invention as disclosed in this Invention Disclosure.Name Signature Date CitizenshipThank you for disclosing your invention to Washington State University.CONFIDENTIAL: This Invention Registration and Disclosure may contain proprietary information and may not bedisclosed to anyone not bound under the terms of a written confidentiality agreement.IAC Invention Registration & Disclosure Page 10 of 10 Revised 10-20-10