AD-761 Panten License Application for Government Invention

Patent License Application

OTT - Patent License Application 1 28 2005 for Collection 0518-0003

OMB: 0518-0003

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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)

File Typeapplication/msword
Last Modified ByAnderson, Yvette
File Modified2015-10-05
File Created2015-10-05

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