Research and Sponsored Programs INTELLECTUAL PROPERTY

Office Use Only
Date ID Received
Internal Ref. No.
Research and Sponsored Programs
INTELLECTUAL PROPERTY DISCLOSURE FORM
INSTRUCTIONS:
1. COMPLETE ALL SECTIONS.
2. ELECTRONICALLY SUBMIT the completed form (pages 1-2 and any additional attachments), to
[email protected] OR SUBMIT COMPLETED HARDCOPY to Research and Sponsored Programs,
200 Memorial Hall.
3. ALL INVENTORS LISTED SUBMIT A SIGNED ORIGINAL HARD COPY OF APPENDIX A to Research and
Sponsored Programs, 200 Memorial Halls.
4. ALL Inventors should retain a copy of Invention Disclosure and Appendices for their records.
Working Title of Invention (descriptive-process / method or composition): Actual title may likely change as
the patent application is prepared.
Description of the Invention: (limit to form and add figure drawings, if necessary)
What is application or objective of your invention? Since this is an initial disclosure, please provide enough information to
inform a non-technical reader about your invention.
1. What does the process, device and/or composition do?
2. How does it do it?
3. What problem does it solve?
4. Why is it new or an important over other inventions, products or research findings?
Sponsorship: Attach additional pages, if necessary.
Funding Source:
Federal
Name of Sponsor
State
Corporate
Grant/Contract Number
MSU
Other
Collaborating Institution/Company or Other Research Support: Attach additional pages, if necessary.
Collaborating Institution/Company Name
Collaborating Investigator’s Name
Did you use materials, equipment, or software from another institution/company?
Yes
No
Public Disclosure Events: Accurate information is essential because prior disclosures may affect the chances of
securing patent rights. Public Disclosures include any published abstracts, publications, meetings and/or presentations
concerning the Invention. Carefully consider all events relating to your Invention that fall into the below categories. Attach
additional pages, if necessary.
Submitted to a Journal:
Published:
Yes
Yes
No
No
Date:
Date:
Journal Name:
Journal Name:
Oral Disclosure:
Poster Presentation:
Other Disclosure:
Any Future Disclosures
planned:
Yes
Yes
Yes
No
No
No
Date:
Date:
Date:
Location:
Published Abstract: Yes
Describe:
Yes
No
Estimated Date:
Handouts: Yes
No
No
Describe:
Commercial Interest: Attach additional pages, if necessary.
Company Name
Is an agreement in place? Yes
Contact Person
Phone Number/E-mail
No
Inventor Data / Primary Contact Person: Attach additional pages, if necessary.
Name:
Home Address:
City/State/Zip:
E-mail:
Home Phone:
Campus Address/Dept.:
Title:
Citizenship:
Office Phone:
Fax:
Inventor Data:
Name:
Home Address:
City/State/Zip:
E-mail:
Home Phone:
Campus Address/Dept.:
Title:
Citizenship:
Office Phone:
Inventor Data:
Name:
Home Address:
City/State/Zip:
E-mail:
Home Phone:
Campus Address/Dept.:
Title:
Citizenship:
Office Phone:
Inventor Data:
Name:
Home Address:
City/State/Zip:
E-mail:
Campus Address/Dept.:
Title:
Citizenship:
Home Phone:
Office Phone:
Appendix A: ALL INVENTORS LISTED MUST SUBMIT A SIGNED ORIGINAL HARDCOPY OF APPENDIX A TO
RESEARCH AND SPONSORED PROGRAMS, 200 MEMORIAL HALL.
Appendix A: Assignment of Inventions Rights
Name:
Minot State University Identification Number (EMPLD):
In consideration of:
 my continued, present and/or future employment at Minot State University (hereinafter referred to as
MSU; and/or
 my status as a graduate student at MSU; and/or
 my participation as faculty, student, volunteer, trainee or staff in research or in an investigation
performed at MSU; and/or
 opportunities made or to be made available to me to make significant use of MSU’s funds or facilities;
and/or
 opportunities made or to be made available to me to share in royalties and other inventor/author rights
outlined in MSU’s Intellectual Property Policy
I hereby agree to abide by all provisions of MSU’s Intellectual Property Policy which are hereby incorporated by
reference and I hereby agree:
A. To comply with MSU’s Intellectual Property Policy which applies to all Inventions made by MSU’s faculty,
staff, students, trainees, volunteers or others if such Inventions are:
i) the result of research performed by or under the direction of any faculty member, staff or
student, the cost of which was partially or wholly paid for with funds under the control of or
administered by MSU and/or
ii) the result of an investigation by the faculty, staff, students, trainees, volunteers or others
utilizing MSU’s facilities, laboratories or other resources available to such faculty, staff,
students, trainees, volunteers or others because of their status within MSU.
B. To disclose promptly to Research and Sponsored Programs full information concerning intellectual
property, inventions, discoveries or know-how (hereinafter “Invention”) that may be made in the course
of any such research, investigation or training program;
C. To assign to MSU or its designee all of my rights, title, or interest to such inventions, discoveries, knowhow, patent applications, patents, certificates of Plant Variety Protection, or the like;
D. To execute all necessary papers and otherwise provide proper assistance at MSU’s expense, during
and subsequent to the period of my MSU affiliation, to enable MSU to obtain, maintain, or enforce for
itself or its nominees, patents, or other legal protection for such Invention;
E. To prepare and maintain for the Institution adequate and current written records of all such Inventions;
and
F. Upon request, to deliver promptly to MSU copies of all written records referred to in Paragraph E above
as well as all related memoranda, notes, records, plans, or other documents.
This agreement may not be modified or terminated, in whole or in part, except in writing, in which case it will be
signed by an authorized representative of MSU. Rights and obligations under this agreement shall survive any
termination of enrollment or employment at MSU.
Signature:
Date:
SIGN IN BLUE INK