INVENTION DISCLOSURE FORM

Instructions: Complete this Invention Disclosure Form to the best of your knowledge and abilities; it is acceptable to submit this form without completing all questions. If a question does not apply, please enter “N/A.” Submit the completed form, manuscript, posters, and any other related attachments to patents@unt.edu

Technology Description

Title of your invention

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What is the current problem or unmet need that your invention addresses?

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How does the disclosed invention provide a solution to the problem or need identified in question 2 above. Please identify the main novel feature(s) that distinguish it from other technologies, products, methods or approaches.

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What is the stage of development of the disclosed technology?

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Check any applicable boxes below that apply to the disclosed technology and provide associated information:

☐ The technology is or includes a device (please provide available diagrams/drawings of the device, labeling and detailing its principal components).

☐ The technology is or includes a process, method, or algorithm (please provide available flow charts detailing the steps of the process, method, or algorithm)..

☐The technology is or includes a composition of matter (please provide available chemical descriptions (i.e., structure, sequence, and/or formula) and the method of synthesis).

Market Considerations

Please provide market knowledge to assist in the process of evaluating the invention. The Innovation & Commercialization team will conduct further review of the potential market during the evaluation.

What competing products or other current solutions exist to solve the problems or needs that you identified, and how do the unique features of your disclosed technology differ from the current solutions?

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Provide us with a list of companies and contacts (if any) you believe might be interested in the technology you are disclosing.

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Public Disclosure, Export Control, and Other Details

Have you disclosed, or do you plan to disclose, the unique feature(s) described above to any party external to the UNT Systems (e.g., company, university, conference abstract/presentation/poster, seminar, journal publication, etc.)?

☐ Yes ☐No

If yes, to whom and when?

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Does the disclosed technology have military, space, nuclear, proliferation, or chemical and biological weapons applications?

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Funding

Identify all funding sources that were used to conceive of or develop the technology you are disclosing.

Describe the internal resources that were used in the development of the technology you are disclosing:

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Identify all external sources of funding used in the conception and development of the technology you are disclosing; include grant numbers or other unique identifiers:

Name of Funding Agency/Entity, Award ID, and/or Project ID

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Inventorship

Identify individuals who conceived the unique features of the disclosed technology described above. Please identify inventors as employees of UNT, Non-UNT employees, or students.

List of Inventors

UNT and non UNT employees, please fill this table. For non-UNT employees please fill out the Institution column

First Name	MI	Last Name	Email	Non- UNT Email (Personal)	Address	Citizenship ( Needed for international filing)	Institution

Students please fill this table below:

First Name	MI	Last Name	Email	Non- UNT Email (Personal)	Address	Academic level	Citizenship ( Needed for international filing)	Received Financial or Monetary Compensation Related to the Project?

Identify one inventor who is a current UNT employee as a primary contact for communication purposes regarding this disclosed technology. This individual should be a faculty member or staff member rather than a student, if applicable. Provide their name and email address.

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Revenue distribution: Net revenue resulting from commercialization of this Invention Disclosure will be distributed consistent with UNT policy 8.003. Please provide how the inventor portion should be distributed among the inventors listed in question 11 above (add more lines as needed). If no distribution percentages are provided here, the inventor portion will be distributed equally among all inventors.

First Name	MI	Last Name	Distribution %
Inventor 1
Inventor 2
Inventor 3
Inventor 4
Inventor 5
Total = 100%

Agreement

I, the undersigned each individually, do hereby represent that to the best of my actual knowledge there are no inventors of the invention disclosed herein other than the inventors named above in this Invention Disclosure. I hereby assign to University of North Texas all right, title and interest in and to this disclosed invention and all patents, patent applications and patent rights worldwide related thereto. I hereby acknowledge my obligations under University of North Texas Invention Policy (we will follow-up with digital signature request when this Invention Disclosure document is complete).

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Inventor 1:

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Inventor 2:

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Inventor 3:

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Inventor 4:

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Inventor 5: