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Invention Disclosure Form

Pursuant to Florida Gulf Coast University (FGCU) Intellectual Property Policy (Policy No. 2.002), “The University is implementing this authority through this Intellectual Property Policy, which requires that all Florida Gulf Coast University employees disclose certain works and inventions that are developed or discovered while affiliated with the University.”

This form is used to disclose generally patentable materials of an invention. All questions included in this disclosure form are important. It is required that the leading inventor provide information to all questions with adequate details. You may provide attachments as necessary.

If you have any questions, please email the Office of Research & Sponsored Programs or call (239) 590-7582

If there are any co-inventors, contact the Office of Research & Sponsored Programs or call (239) 590-7582 before completing this form.

Description of Invention

250 words maximum
3. Does your invention have any practical applications in solving practical, real-world problems?*
250 words maximum
4. Will your invention result in any commercializable product(s)?*
250 words maximum
250 words maximum
4c. Have you developed and tested on working prototype(s) of your product(s)?*
4d. Do you have any potential commercialization partner(s) in contact, or in mind?*
5. Please provide an estimated economic value of your invention if commercialized*
6. Are you aware of any related inventions and/or developments by others?*
9. What is the potential impact of your invention?*

Publications, Public Use and Sale

11. Has the invention been disclosed to the public in the past 12 months?*
12. Has there been any public use or sale of products embodying the invention?*

Sponsorship

13. Please specify if the invention is developed/evolved from a sponsored project, program, grant, contract, etc.*
13c. Has the invention been disclosed to the sponsoring agency or others?*
14. Did you, or any other co-inventors, use or include any already patented materials or processes belonging to others in this Invention Disclosure Form?*

Evaluators

Please provide contact information of at least three individuals other than inventors of this invention, including one from outside FGCU, with technical or economic knowledge in the field of the proposed invention. Evaluators/reviewers could be asked, under confidentiality undertakings, to evaluate or review the proposed invention. The following contact information must be provided:

Evaluator/Reviewer 1

Evaluator 1 Name*

Evaluator/Reviewer 2

Evaluator 2 Name*

Evaluator/Reviewer 3

Evaluator 3 Name*

Inventor Information

Please list names and contact information of all inventors to be included, for example, in the patent application.

This invention was created by
Lead Inventor Name*
Lead Inventor Current business/mailing address*
Lead Inventor Permanent mailing address*
Lead Inventor Permanent mailing address*
Use your mouse or finger to draw your signature above
Date*
Co-Inventor #1 Name*
Co-Inventor #1 Current business/mailing address*
Co-Inventor #1 Permanent mailing address*
Co-Inventor #1 Permanent mailing address*
Co-Inventor #2 Name*
Co-Inventor #2 Current business/mailing address*
Co-Inventor #2 Permanent mailing address*
Co-Inventor #2 Permanent mailing address - Copy*
No File Chosen
File uploads may not work on some mobile devices.
File formats accepted: pdf, doc, docx, txt

More Than 2 Co-Inventors

Be sure to upload a file for all co-inventors that includes:

  • Co-Inventor Full Name
  • Co-Inventor Current business/mailing address
  • Co-Inventor Permanent mailing address
  • Co-Inventor Email
  • Co-Inventor Phone
  • Co-Inventor Signature
  • Date of Co-Inventor Signature
No File Chosen
File uploads may not work on some mobile devices.
File formats accepted: pdf, doc, docx, txt

Once you submit this form, you may NOT go back to make changes. You can use the Save and Resume Later link below to make changes prior to submitting to the form.

Note: Attachments will only be saved upon final submission of the form.

Co-Inventor #1 Signature

Use your mouse or finger to draw your signature above
Date*

Co-Inventor #2 Signature

Use your mouse or finger to draw your signature above
Date*
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