Invention Disclosure - Please complete the following questions

INTELLECTUAL PROPERTY REPORT FORM

What is the title of your innovation?
	A value is required.
Who contributed to this IP?  Please list any individuals who made a material contribution, as well as their affiliation (i.e. Birck, Bindley, ARS, IDI, CERIAS, etc).  If they are a non-Purdue employee, please provide appropriate contact information. (*see at the end of the form for additional space if more than two contributors)
	Name:	A value is required.
	Affiliation(s):	A value is required.
	Email:	A value is required.
	Home Address:	A value is required.
	Country of Citizenship:	A value is required.
	Name:
	Affiliation(s):
	Email:
	Home Address:
	Country of Citizenship:
Describe the IP:  Please provide a technical description of what the IP is and how it works.  If you have a manuscript, research proposal, grant, etc. describing the IP please include a copy, even if it is a preliminary draft.
	A value is required.
Please describe a useful application of the IP (what problem does the IP solve?).
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How does the IP differ than what others are currently doing in your area?
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Has anyone in your group previously described your invention in a journal article or presentation?  If so, to whom and when?
	A value is required.
Are you planning to publish/present this IP in the future?  If so, when?
	A value is required.
Is there external support for the work leading to this invention (NSF, DOE, DOD, Hatch, corporate, etc.)?  If so, what is the entity, grant number, termination date?
	Entity:
	Contract/Grant No.:
	Title:
	Termination Date:
		OR
	No External Funding:
Please make a selection.I provided the above information, which is accurate to the best of my knowledge.
	Signature:	A value is required.
	Date:	1/14/11
Upon successful submission of this report, OTC will contact you to arrange a meeting.
*Additional Contributors: