CENTRE FOR INTELLECTUAL PROPERTY RIGHTS ANNA UNIVERSITY CHENNAI, CHENNAI 600 025.

Sl.No ____ Date:

INVENTION DISCLOSURE FORM

TITLE OF THE INVENTION:

I. CONTACT INFORMATION 1. Name and Nationality of the main inventor: Name Home Address Citizenship Mobile No E mail id

2. Name and Nationality of the additional inventors: Name Home Address Citizenship Mobile No E mail id

II. FUNDING SUPPORT FOR THIS INVENTION 1. Sponsoring agency: (a) Was this invention developed under any project funds): YES (b) If yes Name of the funding agency along with the reference details: NO

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III. ABOUT THE INVENTION 1. Field of the Invention

2. Novelty of the invention

3. Innovative features

4. Abstract of the Invention

5. Background of the invention

6. Existing state of art related to the invention (includes patent, literature search)

a. The kind of Patent search you request (tick) 6.1. Prior art / 6.2 Freedom to operate / 6.3. (Invalidity/Validity)
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6.4. Infringement /6.5. Bibliographic / 6.6. Continuing / 6.7. (Inventor/assignee) 7. Drawbacks in existing state-of-art and how the drawbacks have been overcome and advantages of your invention.

8. Detailed description of the invention

9. Industrial application of the invention

10. List of keywords (in capital letters) relevant to the invention

IV. PUBLIC DISCLOSURE 1. Has the invention been described or discussed in any journal, abstract paper, oral presentation, news story, thesis or other medium? YES a) If yes give the details NO

V. USE OF PROPRIETARY MATERIALS 1. Indicate whether any part of the invention is based on, or was made possible by the use of, Proprietary material(s) or special technique(s) obtained from a third party (such as a company or
Confidential IDF, CIPR, Anna University, Chennai - 600 025 3

another institution). 2. Did this research use any biological material from outside? YES NO a. If yes, please mention the geographical origin of biological material used for the invention

b. If so, have you deposited the biological material in an International Depository Authority? YES NO c. Name and address of the International Depository Authority

d. Date and number of deposition of Biological material:

VI. MARKET EVALUATION 1. Whether your invention is concept only, laboratory tested or prototype.

2. List the products or process that competes with your invention?

3. Suggest few companies (along with their complete contacts) which may be interested in your invention?

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4. Approximate commercialization value of your invention:

VII. GENERAL INFORMATION (Only for the invention of Anna University which are not sponsored through funding agency) 19. List of three expert members (along with their complete contact details) in the field of proposed invention (preferably in and around Chennai).

VIII. SIGNATURE PAGE I/We the undersigned inventor(s), through my/our activities at Anna University, hereby disclose this Invention to the CIPR, Anna University Chennai on the date last signed below. I/We understand that my/our obligations regarding this Invention are governed by the Anna University IPR Policy. Signature of the Inventor(s) By: Name: Date: By: Name: Date:

By: Name: Date:

By: Name: Date:

( Attach additional Signature Pages, if necessary) Please submit the completed Invention Disclosure Form, Detailed Specification of the invention and Signature Page signed by all inventors to: The Director, Centre for Intellectual Property Rights,
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Anna University Chennai 600 025 FOR OFFICE USE ONLY 1. Name of the Person who made the Search: 2. Kind of search made Prior art / Patentability / Freedom to operate / (Invalidity/Validity Infringement /Bibliographic / Continuing / (Inventor/assignee) 3. Name of the person who drafted the specification: 4. Kind of specification: 1. Provisional 2. Complete 5. Date of Filing the provisional specification to the patent office: 6. Date of Filing the Complete specification to the patent office: 7. Date of request for publication: 8. Date of request for examination: / / /20 /20 / / /20 /20

9. Initiatives taken for commercialization:

10. Actions taken by the patent office:

11. Details of any pre grant oppositions filed:

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12. Date of counters filed to the Patent office:

14. Date of Grant of patents:

/20

15. Details of any post grant oppositions:

16. Details of Final Decision on the Patent:

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