AD-761 Panten License Application for Government Invention

United States Department of Agriculture PATENT LICENSE APPLICATION FOR GOVERNMENT INVENTION Submit an original form to – Coordinator, Technology Licensing Program, U.S. Department of Agriculture, Agricultural Research Service, 5601 Sunnyside Ave.; Rm 4-1159, Beltsville, MD 20705-5131. The signed and dated license application may also be faxed to (301) 504-5060 or e-mailed as a PDF to [email protected].			1. AGENCY PATENT CASE NO. (Optional)      
			2. U.S. PATENT NO.      
			3. DATE OF PATENT      
6. TITLE OF PATENT/PATENT APPLICATION      			4. U.S. PATENT APPLICATION SERIAL NO.      
7. SOURCE OF INFORMATION CONCERNING AVAILABILITY OF THIS INVENTION      			5. TYPE OF LICENSE Exclusive Nonexclusive
8. NAME AND ADDRESS OF APPLICANT      		9. NAME AND ADDRESS OF REPRESENTATIVE TO WHOM CORRESPONDENCE SHOULD BE ADDRESSED      
10. STATE OF INCORPORATION (if corporation) or CITIZENSHIP (if an individual)      		11. TELEPHONE, FAX, AND EMAIL      
12. NATURE AND DESCRIPTION OF APPLICANT’S BUSINESS – Identify products or services successfully commercialized.      
13. APPROXIMATE NUMBER OF EMPLOYEES      		14. IS APPLICANT A SMALL BUSINESS CONCERN? YES NO
15. FIELD(S) OF USE IN WHICH APPLICANT INTENDS TO PRACTICE INVENTION      
16. IS APPLICANT WILLING TO ACCEPT A LICENSE FOR LESS THAN ALL FIELDS OF USE AS INDICATED IN ITEM 15 ABOVE? YES NO
17. SPECIAL TERMS OR CONDITIONS OF LICENSE DESIRED      
18. APPLICANT’S BEST KNOWLEDGE OF EXTENT TO WHICH THE INVENTION IS BEING PRACTICED BY PRIVATE INDUSTRY AND/OR GOVERNMENT, OR IS OTHERWISE AVAILABLE COMMERCIALLY      
19. GEOGRAPHIC AREAS IN WHICH APPLICANT INTENDS TO MAKE, USE, AND/OR SELL THIS INVENTION      
20. DETAILED DESCRIPTION OF DEVELOPMENT AND/OR MARKETING FOR EACH FIELD OF USE TO WHICH RIGHTS ARE SOUGHT (PLEASE REVIEW INSTRUCTIONS)      
21. ADDITIONAL INFORMATION TO SUPPORT APPLICATION      
22. Application is made for a license to practice in the United States, the Government-owned invention identified herein, in accordance with 35 USC 208	SIGNATURE OF APPLICANT or AUTHORIZED REPRESENTATIVE			DATE

Form AD-761 (continued)