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WIPO AWARD-Nomination form

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WIPO AWARD-Nomination form Powered By Docstoc
					               AFRICAN UNION                                                                           WORLD INTELLECTUAL
                                                                                                      PROPERTY ORGANIZATION




                        “BEST INVENTION/INNOVATION IN AFRICA”

                                                   NOMINATION FORM

       To be completed and submitted by the national organizing/selection committee to the
Secretariat of the African Union (AU) - WIPO Invention and Innovation Award Program, at
the African Union Headquarters, in Addis Ababa, Ethiopia (see complete address at the end of
this form)


I.      Information Concerning the Inventor(s)/(Nominee(s)):

1.      Personal data:

        Country: .............................................................................................................................
        Surname: (block letters) ......................................................................... .(Mrs./Miss/Mr.)
        First name: (block letters) ..................................................................................................
        Present occupation (position, company): ...........................................................................
        ............................................................................................................................................
        ............................................................................................................................................
        ............................................................................................................................................
        Please attach a short curriculum vitae of the inventor/nominee.
        Note : If the invention/innovation is the result of collective work (a team), please
                     provide the same information for all team members and specify the team
                     leader.
        Full address:
        ............................................................................................................................................
        ............................................................................................................................................
        ............................................................................................................................................
        Telephone numbers: (official) ..................................... (private) .........................................
        Facsimile numbers: (official) ...................................... (private) .........................................
        E-mail address: .................................................................................................................

                                                                                                                                                 /...
2.      Name of enterprise or institution where the nominee is employed (if applicable) and
        field of activity:
         ............................................................................................................................................
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                                    AU-WIPO Invention and Innovation Awards
                                              Nomination Form
                                                    page 2


      ............................................................................................................................................
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3.    Field of technology for the submission: list to be revised with the AU Secretariat

               Health
               Energy
               Food Technology
               Water supply / Sanitation
               Others (please specify) ..............................................................................................
               ...................................................................................................................................
               ...................................................................................................................................

4.    Category of award (please select one of the following):

               Best Invention/Innovation
               Woman Inventor
               Young Inventor



II.   Information on the Invention/Innovation:

1.    Title of the invention/innovation - it should be recent (created in or after 2003 or 2004)
      ............................................................................................................................................
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                                   AU-WIPO Invention and Innovation Awards
                                             Nomination Form
                                                   page 3


2.   Full description
     (if necessary use additional pages; pictures, drawings and abstracts may be attached
     including a description of the process followed in developing the invention/innovation)
      ............................................................................................................................................
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      ............................................................................................................................................
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     Note :        Each submission should contain an abstract or summary of the essence of the
                   invention/innovation, in English and French.

3.   Presentation of the merits and advantages of the invention/innovation, indicating
     problems and constraints encountered and how they were overcome:
     ............................................................................................................................................
     ............................................................................................................................................
     ............................................................................................................................................
     ............................................................................................................................................
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4.   If a patent (or utility model) or patent application exists, please provide the full list of
     patent applications and/or granted patents, in chronological order, specifying:

     -        number and type of document of protection (patent or utility model) or application
     -        country (office) and date of application or grant
     -        priority date (if different from application date)

     ............................................................................................................................................
     ............................................................................................................................................
     ............................................................................................................................................
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     Please attach a copy of a patent document or (at least)a copy of the first page of the
     patent document (usually containing bibliographic data, abstract and drawing).
     Note :      If several applications or patents exist, all should be listed.
                                                                                                                                              /...
                                   AU-WIPO Invention and Innovation Awards
                                             Nomination Form
                                                   page 4


5.   Please list other industrial property titles covering the invention/innovation, such as
     trademarks, industrial designs, etc. (including date of application/registration
     office/country of registration, number of application, etc.)
      ............................................................................................................................................
      ............................................................................................................................................
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6.   State of development of the invention/innovation (laboratory stage, prototype,
     industrial or commercial use and since when):
      ............................................................................................................................................
      ............................................................................................................................................
      ............................................................................................................................................
      ............................................................................................................................................

7.   Attach a recent state-of-the-art search report on the proposed invention/innovation,
     prepared by a national or regional industrial property office or by WIPO, and dated not
     earlier than six months before the date of the nomination.
      ............................................................................................................................................
      ............................................................................................................................................

8.   Who has already used the invention/innovation (governmental institutional or agency,
     private sector)? (Please attach references or comments from users, if available.)
     ............................................................................................................................................
     ............................................................................................................................................
     ............................................................................................................................................
     ............................................................................................................................................



9.   Has the invention/innovation been licensed or used in a joint venture in the country of
     origin or abroad (provide details in case of affirmative)?
     ............................................................................................................................................
     ............................................................................................................................................
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                                       AU-WIPO Invention and Innovation Awards
                                                 Nomination Form
                                                       page 5


10.      Impact (or expected impact) of the invention/innovation on the economic and social
         development in the country of origin and Africa:
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11.      Local materials used:
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12.      Significance (importance) of the invention/innovation and specifically its impact on
         large population communities:
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          ............................................................................................................................................
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13.      Please list and attach any other documents or information which provide more detailed
         information on the invention/innovation.
          ............................................................................................................................................
          ............................................................................................................................................
          ............................................................................................................................................
          ............................................................................................................................................
          ............................................................................................................................................



III.     Conclusions/Recommendations by the National Selection Committee

    A short summary of the conclusions/recommendations of the National Selection
Committee, including the rationale for the choice/selection
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................



                                                                                                                                                  /...
                                      AU-WIPO Invention and Innovation Awards
                                                Nomination Form
                                                      page 6


IV.      Deadline and Mailing

1.       The AU Secretariat, in Addis Ababa, must receive the completed nomination form with
         the attachments not later than [date]. Submissions received after that date will not be
         considered for the final selection.

2.       The completed forms (in three (3) copies in one of the AU official languages) must be
         sent to:

                           AU Commission – HRST Department
                           The Secretariat
                           African Union (AU)
                           P.O. Box 3243
                           Addis Ababa, Ethiopia
                           Fax No. (251-11) 5505928 or (251-11) 551 78 44
                           E-mail: hamdya@africa-union.org, hambanim@africa-union.org

         Not:              This nomination form can also be downloaded from the “AU-WIPO
                           Invention and Innovation Award program” http://www.africa-union.org


                            Certification by the Nominating Organization/Committee

Surname: (block letters) .................................................................................. .(Mrs./Miss/Mr.)
First name: (block letters) ...........................................................................................................
Present official title: ....................................................................................................................
Organization/Committee: ............................................................................................................
Full address:
       ............................................................................................................................................
       ............................................................................................................................................
      Telephone numbers: ...........................................................................................................
      Facsimile numbers: ............................................................................................................
      E-mail address: .................................................................................................................


                           Date: .........................................         Signature: . .............................................

(Seal)



                                           Certification by the Inventor/Nominee

                           Date: .........................................         Signature: . .............................................

				
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