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									                                   UTI Limited Partnership



                              Technology Disclosure Form
                                     for University of Calgary Researchers
                (Microsoft Word template version - fill in, print out, sign and return to UTI.
              Use TAB key to move to the next field. To go back, click mouse in desired field.
                              Use mouse click or type X in a check box.)
 ______________________________________________________________________________________

UTI’s Technology Disclosure Form is filled out when you, as an inventor/author, want commercialization
assistance from UTI on:
• something new and commercially useful you have conceived or developed, or
• when unusual, unexpected or unobvious research results have been achieved.

Completing this form discharges your responsibility to the University of Calgary to disclose any inventions as
per its Intellectual Property Policy, Section 4.3. The extent to which research is materially supported by the
University or conducted using University facilities and resources will determine the University’s economic
interest (revenue share) in the technology. This form does not obligate you to use UTI or any of its services to
commercialize your invention. The information on this form is confidential among the inventor(s), UTI and
University administration.

Instructions:
Page 2: The following instructions apply to the corresponding numbered sections:
  1. Use a brief, descriptive, layman's title to aid in identifying the technology.
  2. Give the applicable contract or grant number(s) if the invention was made in connection with any sponsored research. If there is a
       University project account number, please include it here.
  3. Check the appropriate box.
  4. Complete all parts of section 4 in view of the following:
      a) "First publication" means the first time any member of the general public (without restriction of confidentiality) would have
      been legally able to gain access to a detailed, written, printed or online description of the invention. This includes abstracts
      submitted to conferences.
      b) "First public oral disclosure" refers to the oral equivalent of 4a.
      c) Enter the anticipated date of publication (as described in 4a above.)
  5. Describe the technology addressing the following points (attach additional pages if necessary:)
       a) General purpose
       b) Technical description; current state of development.
       c) Advantages and improvements over existing methods, devices or materials.
       d) Commercial applications (economic potential, interested companies.)
  6. Obtain the Department Head’s signature.

Page 3: List the name and contact information for the all inventors and indicate the Main Contact Inventor.
                                          All inventors must sign the form.
           ____________________________________________________________________________________________________

Send the form with Pages 2 and 3 completed through Campus Mail ("UTI") or forward to:

                                               UTI Limited Partnership
                              by its General Partner, University Technologies International Inc.
                                       130 3553 31 St. NW, Calgary, Alberta, T2L 2K7
                                         Tel: (403) 270-7027, Fax: (403) 270-2384
                         TECHNOLOGY DISCLOSURE FORM
                               for University of Calgary Researchers
 The information on this form will be kept confidential, but may be transmitted to the University administration.
                                           See Page 1 for instructions.
       ____________________________________________________________________________

1. Title of Invention:

2. Contract or Grant Number(s)       Sponsors                               Principal Investigator




3. Were University of Calgary funds or facilities used in the development of this technology?
                    No                                   Yes

4. Events                            Date            References/Comments (use separate sheet if necessary)
   a) First publication
   (See Page 1 for definition)

  b) First public oral disclosure
  (See Page 1 for description)

  c) If unpublished, provide the
  anticipated publication date.

5. Description of the technology (see instructions, use additional sheets if necessary)



Department Head’s Signature ____________________________                Date ______________
                      DISCLOSURE FORM INVENTOR LIST
                             for University of Calgary Researchers
       ______________________________________________________________________

Inventor information details.        Attach additional sheet if necessary.

Name of Contact Inventor


Inventor
Name (specify Dr./Mr./Ms.)
University Department
Address                                  Room #
City/Province
Phone/Fax                         Fax:
Email

Inventor
Name (specify Dr./Mr./Ms.)
University Department
Address                                  Room #
City/Province
Phone/Fax                         Fax:
Email

Inventor
Name (specify Dr./Mr./Ms.)
University Department
Address                                  Room #
City/Province
Phone/Fax                         Fax:
Email

Inventor
Name (specify Dr./Mr./Ms.)
University Department
Address                                  Room #
City/Province
Phone/Fax                         Fax:
Email



Signatures                                                  Date                  % Contribution

Inventor ____________________________________               ___________           ______________

Inventor ____________________________________               ___________           ______________

Inventor ____________________________________               ___________           ______________

Inventor ____________________________________               ___________           ______________

                              (Attach separate sheet for additional inventors.)

								
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