Legal Collections Package

OMB Control No. 1910-0800 Exp. Date:  XX/XX/XXXX

DEPARTMENT OF ENERGY

NONEXCLUSIVE PATENT LICENSE APPLICATION

It is the policy of the U.S. Department of Energy (DOE) to accord licensed on DOE-owned patents applications in appropriate circumstances to applicants with satisfactory plans for development and/or marketing of the invention. 37 CFR Part 404, Licensing of Government Owned Inventions, provides terms, conditions, and procedures for the accord of patent licenses, both nonexclusive, on DOE-owned patents and patent applications.

An application for a nonexclusive license should set forth the following, and, in addition, any other information that applicant deems would be of importance to show that the accord of a non-exclusive license is in the public interest. The application must be accompanied by a processing fee of $25.00. The check or money order should be made payable to the U.S. Department of Energy.

Applications should be addressed to:

Assistant General Counsel

for Technology Transfer

and Intellectual Property

1000 Independence Avenue, S.W.

Washington, D.C. 20585

INFORMATION REQUIRED:

1. Identification of Applicant

1. Name:

2. Address:

3. Citizenship and State of Incorporation:

4. Name, title, and telephone number of representative of applicant with whom negotiations are to be considered:

2. Identification of Invention

1. Patent Number of Patent Application Serial Number:

2. Title:

3. Nature and type of applicant’s business, including identification of products or services which applicant has successfully commercialized, and including approximate number of applicant’s employees:

4. Applicant’s status, if applicable, as a small business, as defined at section 2 of Pub. L. 85-535 (15 USC 632) and implementing regulations of the Small Business Administration:

5. Identification of source of information concerning the availability for license of the invention:

6. In support of this application, please submit, as an appendix hereto, a detailed description of applicant’s plan for development and/or marketing of the invention, which should include:

1. A statement as to applicant’s intention to fulfill the plan, including applicant’s manufacturing, marketing, financial, and technical capability to fulfill the plan;.

2. A statement of the time, nature, and amount of anticipated investment of capital and other resources which applicant believes will be necessary to bring the invention to practical application;

3. A statement of the field or fields of use for which applicant intends to practice the invention; and

4. A statement of the geographic areas in which applicant intends to manufacture, use, or sell any products embodying the invention or produced through the use of the invention.

(Signature)

(Name and title of authorized representative)

Date:

Enclosure: Check in the amount of $25.00

Payable to: United Stated Department of Energy

Public reporting burden for this collection of information is estimated to average 7.7 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-23, Paperwork Reduction Project OMB control number 1910-0800, U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project OMB control number 1910-0800, Washington, DC  20503.