Fillable CopyrightableWorksForm 4 27 2017C ReaderExtended

Fill Online, Printable, Fillable, Blank CopyrightableWorksForm 4 27 2017C ReaderExtended Form

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CopyrightableWorksForm 4 27 2017C ReaderExtended

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U.S.A. forms for Tennessee Technological University

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1
Tennessee Tech
COPYRIGHTABLE WORK DISCLOSURE FORM
(Attach additional sheets as needed.)
1. Title of the Work:
2. Author information:
Name: ____________________________________
Position:___________________________________
Department:________________________________
E-mail:____________________________________
Phone:____________________________________
Nature of Contribution:
3. Funding
Please indicate any source of funding associated with the research leading to the work:
o Federal Government
o External, other than Federal Government
o Internal
o None
If work was made wholly or in part as a result of external funding, please provide the
following information:
Sponsoring Agency:__________________________
Contract or Grant Number: ____________________
Please attach a copy of the contract associated with the external funding.
2
4. Other support
For each of the inventors, were you specifically assigned to work on the invention by
your supervisor? Did you work on development of the invention during your normal work
hours?
Has the Institution provided support to the development of the invention by providing
resources, materials or access to facilities and equipment? If yes, please describe.
5. Description of the Work
Briefly summarize the nature of the Work. Describe any commercial potential you see
for the Work.
3
6. Potential Licensees
Please list any companies, and contacts within those companies, if known, which you
believe might be interested in licensing this work:
I have reviewed and concur with the information contained in the statement.
Printed Name __________________________________________________
Author 1 Signature and date ______________________________________
Department Chairman Signature and Date
________________________________________________
Dean of Author’s Institution Signature and Date
________________________________________________
ALL INFORMATION CONTAINED HEREIN IS CONSIDERED CONFIDENTIAL
INFORMATION OF THE TENNESSEE BOARD OF REGENTS.
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CopyrightableWorksForm 4 27 2017C ReaderExtended

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Completed 12 March 2020

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