UCI Copyright Case No. SOFTWARE/COPYRIGHT DISCLOSURE FORM Information contained in this disclosure is CONFIDENTIAL and PROPRIETARY. For assistance, please call the Office of Technology Alliances at (949) 824-7295. This disclosure will normally not be released to others by OTA except under attorney client privilege, to research sponsors as required by contract, under appropriate secrecy agreements, or as may be required by law. This disclosure should not be disclosed to others without the approval of OTA. 1. Title of Software: Create a short title (10 words or less) for the software 2. Brief Description: Provide a brief, 2 to 3 sentence description of the software in terms of its general utility and primary application(s): (ie “what will this be used for?”). 3. Authors/Inventor(s)*: The first person listed will be the “lead,” which is OTA’s point of contact for the software. Name: Position at UCI: School or Division: Dept. or ORU: Campus Address with Zot Code: Irvine, CA 92697Work Phone: Date(s) of Employment at UCI: Home Address: address city,state,zip Mobile Phone (optional): UCI Email: Other Email: By signing below and for good and valuable consideration, the undersigned do hereby ASSIGN AND TRANFER TO The Regents of the University of California the entire right, title and interest in and to the above referenced software and its documentation, if any. Signature:____________________________________________________________ *Please fill out the Additional Author/Inventor Supplemental if there is more than one author/inventor. 4. Funding: Was this software funded/sponsored in any way? Yes No If yes, list the funding source(s). If applicable, identify by contract or grant number and name the Principal Investigator / Supervisor of each. Funding Source / Sponsor Contract or Grant Number Principal Investigator / Supervisor 5. 3rd Party Code**: Provide a complete list of all third party code embedded in or accessed by the disclosed software when such software is run. This list must include, without limitation, all open source code, free executable code, public domain code, library code, and all other executable or source code, including code written by any of the Authors listed in section 3 of this form. Name of Third Party Code Web Page for Code Download Web Page for Third Party License **If the third party code is not available on the web, please provide copies of any license agreements governing the use of such code. UCI Copyright Case No. SOFTWARE/COPYRIGHT DISCLOSURE FORM Page 2 of 3 6. Publication/Distribution: Has any part of the software been published or distributed outside of UC Irvine? Elaborate as needed. 7. Detailed Description of Software: A) Motivation/utility/advantages: please describe the software in terms of its specific utility and applications. Consider addressing the following topics: Motivation for creating the software (such as the problem that this solves or addresses) Advantages over existing software Applications/uses B) Technical details: please describe the technical details of this software and attach additional material as necessary. Address issues such as: C) hardware requirements operating system requirements programming language user interface drawings/schematics/flow charts required utilities required distribution format significance of 3rd party code (section 5 above) Current State of Development: please describe the current state of development and next steps planned. Include a timeline for future work if appropriate. 8. Marketing: The following questions are designed to assist you and the licensing officer assigned to your case in identifying the best commercialization path for this software. Answer only the questions that are relevant to your vision of how the software could be commercialized or otherwise utilized. Describe the audience for whom the item was designed – who will actually use it? What are the commercial uses for your software? Are there similar items currently in the marketplace? Why is this better? Does this solve a previously unsolved problem? Are you willing to assist potential licensees with use and future development of the software? What companies do you believe would be interested in licensing or distributing the software? Estimate the level of customization and/or support the software will need once licensed. What industry groups or professional associations include members potentially interested in this work? UCI Copyright Case No. SOFTWARE/COPYRIGHT DISCLOSURE FORM Page 3 of 3 Please submit the ORIGINAL with SIGNATURES directly to: Kevin Kennan Associate Director Office of Technology Alliances 5141 California, Suite 200 Irvine, CA 92617 Zot 7700 Please also email a scan of the document with signatures to email@example.com.