to Additional Signature Page IPD Form PDF format.

UAB RESEARCH FOUNDATION INTELLECTUAL PROPERTY DISCLOSURE FORM
(additional IPD signature form)
Date:
Title of Invention:
Contact Information:
Email:
Lead Discloser:
Office Phone:
Fax:
Disclosers: Please list all persons believed to have made essential contributions to the Intellectual Property during the
evolution of the initial concept or reduction to practice. Include UAB as well as non-UAB persons and obtain signatures from
all Disclosers. (Fax signatures of non-UAB personnel will be accepted.) Determination of inventorship is a legal matter and
will be determined by legal counsel.
Discloser #6
Printed Name:
BlazerID:
Country of Citizenship:
Campus Address:
UAB Employee VA Dual Emp./WOC
Yes
No
Yes
No
Email:
Daytime Phone:
Home Address:
Signature
Discloser #7
Printed Name:
Date:
BlazerID:
Country of Citizenship:
Campus Address:
UAB Employee VA Dual Emp./WOC
Yes
No
Yes
No
Email:
Daytime Phone:
Home Address:
Signature
Discloser #8
Printed Name:
Date:
BlazerID:
Country of Citizenship:
Campus Address:
UAB Employee VA Dual Emp./WOC
Yes
No
Yes
No
Email:
Daytime Phone:
Home Address:
Signature
Date: