VCOM Institutional Policy and Procedure Manual

Intellectual Property Disclosure

Description of Invention

Type of Work: Invention

Software

Other

Describe:

Title of Intellectual Property: Brief description of invention and purpose (100 words or less):

Please attach full description of Intellectual Property on additional sheet(s) as needed. Is this IP associated with a previous disclosure to VCOM? Yes No If yes, VCOM Case No.

Originators / Inventors List any individual who has conceived or contributed to an essential element of the intellectual property during the evolution of the technology concept or reduction to practice. Please include ALL originators/ inventors in this section, even if not associated with VCOM. List originators/inventors in the order you would like them to appear on a patent application or other form of intellectual property protection.

Name: Originator/Inventor (1) Phone

Fax

Email

Title & Department:

Name: Originator/Inventor (2) Phone

Fax

Email

Title & Department:

Name: Originator/Inventor (3) Phone

Fax

Email

Title & Department:

Name: Originator/Inventor (4) Phone

Fax

Email

Title & Department:

If there are more than four originators/inventors, please enter their information on an additional sheet.

CONFIDENTIAL

VCOM

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VCOM Case Number: ________