NORTHERN CARIBBEAN UNIVERSITY
INVENTION DISCLOSURE FORM
Date:
[List (1) the date this Disclosure was prepared or (2) any earlier date of documented conception]
Title:
[Short title of Invention]
Name, Address & Nationality of Inventor(s):
[List the name, nationality, addresses & contact no. of each Inventor]
Status of Inventor(s):
[State whether Student, Faculty member, Staff or Visitor]
Faculty/Department to which the Inventor(s) is assigned:
Name of Department Head and Research Supervisor [if any]:
Details of reporting the existence of invention:
[State when and how the invention was reported to the Department Head and/or Research
Supervisor]
State whether the invention resulted from a research or other project of the NCU:
[If yes, give details: - project name, description, funding source and names and titles of all persons
working on the project. If no, give details of the provenance of this invention]
Inventors’ contribution:
[If there are two (2) or more inventors, state the following]
1) how each contributed to the invention:
2) how your share of any net proceeds of commercialization is to be divided. [indicate percentage
share]
NORTHERN CARIBBEAN UNIVERSITY
INVENTION DISCLOSURE FORM
Field and Business Relevance:
[Indicate the Field of the Invention and describe the relevance of this invention, if any, to any
business]
Description of the Problem Solved by This Invention:
[Describe the problem that this invention solves]
Prior Art Searches:
[State whether a prior art search was conducted and if yes, give details and attach the results of the
search.] Note that failure to submit prior art search results together with this form will result in a
delay of a determination by the IPMC.
Description of any Prior Art Solution(s) to the Problem:
[Describe how the prior art addresses the problem and the shortcomings of the prior art]
Description of the Invention:
[Describe in detail the invention and attach supporting drawings or figure]
Short Description of Attached Figures or Other Attachments:
[include a list and short description of any attached figures or other materials]
Related Invention Disclosure(s) and/or Patent(s) and/or Application(s):
[list any related invention disclosures, patents or applications]
Relevant Documents or Materials:
[List/attach any know prior art or supporting materials or references including patents, articles, texts,
etc.]
NORTHERN CARIBBEAN UNIVERSITY
INVENTION DISCLOSURE FORM
Prior Disclosures:
[State whether you have disclosed the invention to any third party. If so, please give name, title,
relationship of person to NCU and the date(s) and circumstances of the disclosure(s)]
To be valid, this form must be signed and dated by the Inventor; where there is more than one
inventor it must be signed and dated by each Inventor.
Upon completion, this disclosure form together with any additional sheets and attached documents
must be addressed to, and lodged at, the office of the Chair of the Intellectual Property Management
Committee (IPMC) in a sealed envelop marked HIGHLY CONFIDENTIAL. Disclosure Forms incorrectly
addressed will not be opened by the IPMC. Incomplete forms and absence of any required information
will result in a delay of a determination by the IPMC.
Statement:
I/we have created intellectual property disclosed herein which I/we believe to be
an_______________________________________ [indicate whether an invention, improvement,
discovery or new plant variety]
I/we have read the University’s Intellectual Property Policy and understand that I am/we are
bound by the Policy and must maintain confidentiality throughout the disclosure and
determination process.
Name of Inventor:
Signature: _____________________
Date: ________________________
Name of Inventor:
Signature: _____________________
Date: ________________________