Case No:

Licensing Officer:

1. TITLE OF INVENTION:

2. DESCRIPTION OF INVENTION:

3. IDENTIFY THE PRODUCTS OR SERVICES A COMPANY MIGHT DEVELOP USING THIS TECHNOLOGY:

4. EXPLAIN HOW THE INVENTION IS TECHNICALLY DISTINCT FROM AND SUPERIOR TO THE STATE OF THE ART AND WHAT COMPETITIVE ADVANTAGE IT AFFORDS A LICENSEE:

5. LIST ANY RELEVANT COMPETING INVENTIONS AND PATENTS (to search see: http://www.uspto.gov/patft/index.html and http://pctgazette.wipo.int/):

6. NEXT STEPS REQUIRED TO VALIDATE THE INVENTION:

7. INVENTORS (please indicate the following)

Name:
SS#:
Citizenship:
Position:
Dept:
Wk. Address:
Wk. Phone:
Fax:
Email:
Hm. Address:
Hm. Phone:

Name:
SS#:
Citizenship:
Position:
Dept:
Wk. Address:
Wk. Phone:
Fax:
Email:
Hm. Address:
Hm. Phone:

Name:
SS#:
Citizenship:
Position:
Dept:
Wk. Address:
Wk. Phone:
Fax:
Email:
Hm. Address:
Hm. Phone:

8. FUNDING SOURCE(S) Give the full applicable contract or grant number(s) used for your research in development of this invention (please include industry sponsored research, non-profit funding, governmental funding, applicable fellowships, etc.).

9. EVENTS

A. Initial Idea
Date:
References and Comments:

B. First description of complete invention, oral or written (conception)*

Date:
References and Comments:

C. First successful demonstration, if any (first actual reduction to practice)*

Date:
References and Comments:

D. First publication, abstract, theses, webpostings, etc. containing full description of invention (establishment of publication bar)*

E. External oral disclosures (including seminars, group meetings, etc.)

Date:
References and Comments:

F. Impending publications or oral disclosures (NOTE - please alert the OTM well in advance of any public disclosures to allow enough time for the OTM to make informed decisions regarding possible patent protection; public disclosure can negatively impact the OTM's ability to obtain foreign patent protection).

Date:
References and Comments:

10. THIS INVENTION USED DATA OR MATERIALS INVOLVING:

( ) Material Transfer Agreement - "MTA" (non-UC material)
( ) A subscription to the Celera Database
( ) Affymetrix microarrays
( ) Cre/lox technology

11. COMPANIES THAT COULD BE INTERESTED: (NOTE ‚ if any inventor has a financial interest in a company that might be interested, DO NOT identify that company here; contact the OTM Director to discuss next steps):

12. I HEREBY ASSIGN ALL RIGHT, TITLE, AND INTEREST, INCLUDING BUT NOT LIMITED TO COPYRIGHT AND COPYRIGHT RIGHTS, PATENT RIGHTS AND PROPERTY RIGHTS, IN THE INVENTION DISCLOSED HEREIN TO THE REGENTS OF THE UNIVERSITY OF CALIFORNIA.

Inventor's Signature:
Date:

Inventor's Signature:
Date:

Inventor's Signature:
Date:

13. INVENTION UNDERSTOOD BY

Witness' Signature**:
Date:

Witness' Signature**:
Date:

* see instructions
** please have PI sign if PI is not an inventor; a suitable witness is someone who has a reasonable understanding of the invention but is not an inventor and has no vested interest in the invention.