RESPONSES ARE REQUIRED IN ALL FIELDS
CONFIDENTIAL (NCARS and NCSU Office of Technology Transfer Use Only)
NCSU File No. (Assigned by OTT)
Law Firm File No.
NCSU PROPOSAL FOR PLANT CULTIVAR RELEASE
This form must be signed by the Department Head and the College Dean/Associate Dean prior
to submission. Submission is not complete without including breeding history and
comparisons to other varieties.
Inventor's Name (Primary Point of Contact): ______________________________________________
Citizenship:
Title:
Department:
Campus Address:
Telephone:
Email:
Permanent Address:
City:
Telephone:
Country:
State:
Inventor's Name:
Title:
Campus Address:
Citizenship:
Department:
Telephone:
Email:
Permanent Address:
City:
Telephone:
Country:
State:
Inventor's Name:
Title:
Campus Address:
Citizenship:
Department:
Telephone:
Email:
Permanent Address:
City:
Telephone:
Country:
State:
Inventor's Name:
Title:
Campus Address:
Citizenship:
Department:
Telephone:
Email:
Permanent Address:
City:
Telephone:
Country:
State:
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1.
Type of plant/crop proposed for release:______________________________________________________
2.
Date Variety Conceived or Generated (Conception Date):
3.
Supporting Data Notebook No. ____________________________________________________________
Pages
4.
Has information related to the Variety been published or disclosed:
(Note: Publications may include posters, abstracts, funded grants, grant applications, manuscripts, theses,
research reports to funding agencies, seminars, press releases, interviews, etc.)
Orally:  Yes  No
In writing  Yes  No
If Yes, please explain below;
a.
b.
c.
When:
Authors:
Any changes in the Invention since public disclosure (please attach copies of any publications, if
available):
5.
Designation used for breeding line/variety used in experimental and developmental stages:
______________________________________________________________________________________
6.
Proposed cultivar name to be used after release: _______________________________________________
7.
Please provide a summary of the unique, novel or superior characteristics justifying release (if justification
is based on broadening of genetic base to reduce vulnerability, please note). Attach to this form a detailed
statement of performance of the proposed cultivar, including statistical comparison with standard cultivars,
information needed to establish is as “unique” or “novel” and also concerning its development (dates of
establishment as “novel” cultivar (see item 1) or actual production, etc.). See Rules and Regulations at
http://www.ams.usda.gov/science/PVPO/PVPO_Act/whole2.pdf
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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OTHER PERTINENT DATA
8.
Is a publication or oral disclosure descriptive of the Invention planned within the next six months? (This
includes dissertations, and presentations to anybody outside of NCSU).
 Yes  No
If yes, please give the date (estimate, if known) and attach copies of any existing manuscripts, preprints,
abstracts or poster material.
9.
Recommended Procedure for release (Please review Section B of NCARS Plant Variety Protection Policy
and Procedure Statement).
a.
b.
c.
Unconditional Public Release
Non- Exclusive Release (License to one or more agents)
Exclusive Release (Bid Process to identify single agent)
10. Should a plant patent application or an application for plant variety protection be filed?

Yes
 No
If yes, please describe and estimate the likelihood that a similar variety may be developed elsewhere or the
reason there is urgency (sale of variety, etc).
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
11. Should a utility patent be filed associated with this plant variety? (Utility patents are issued for an
invention of a new and useful process, machine, manufacture, or composition of matter, or a new and
useful improvement thereof)

Yes
 No
12. Should royalties resulting from licensing activities associated with this variety be equally shared by all
inventors listed? (You will be contact by a representative from NCARS or OTT if a non-standard
distribution is suggested)

Yes
 No
13. Certification of seed or materials required:

Yes
 No
14. Please note the availability of breeder seed or other plant material as required and who will be responsible
for maintaining seed.
______________________________________________________________________________________
15. If applicable, proposed arrangement for Foundation Stock increase and which party is responsible for
distribution of Stock.
______________________________________________________________________________________
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16. Have any graduate students and/or other technicians been involved in this research?

Yes
 No
If yes, should the individual(s) be included as a co-inventor?
______________________________________________________________________________________
______________________________________________________________________________________
17. What source(s) of funding was/were used to develop the Invention and was the Invention sponsored by
industry or funded by State or Federal appropriations? If so, attach a copy of the contract or agreement and
fill in any applicable appropriate blanks below. One of the below MUST be completed. (This includes the
source(s) of funds for the salary of each inventor.)
a.
Complete Name of Government Agency: ___________________________________________________
Contract or Grant No. ___________________________________________________________________
b.
Name of Industrial Company: _____________________________________________________________
c.
Name of Private Sponsor: ________________________________________________________________
d.
State or Federal Appropriations: __________________________________________________________
e.
Please list all relevant NCSU Account Numbers: ______________________________________________
18. a. Please list any companies that have been contacted or should be contacted about licensing and
commercializing the variety:
Company Name:
Contact Information:
b. Please check all that apply
 Contacted about the technology – only provided non-confidential information
 Disclosed information about this invention under Confidentiality Agreement
 Company was not contacted, but inventors feel that the company might be interested.
 Disclosed confidential information to the company without signing a Confidentiality
Agreement
19. Has the variety been disclosed to industry representatives?
 Yes
 No
Has any commercial interest been shown in it?
 Yes
 No
If Yes, please name companies; listing specific individuals and their titles if you know them.
______________________________________________________________________________________
______________________________________________________________________________________
20. Have any materials or information been supplied to non-industry contacts (breeders or collaborators at
other institutions under terms and conditions of a NCSU MTA or CDA)?

Yes
 No
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21. Were any patented traits, genes, genetic sequences, or methods used in the development of the germplasm
proposed for release?

Yes
 No
If Yes, please identify the components used.
______________________________________________________________________________________
______________________________________________________________________________________
22. Have any materials or confidential information belonging to another institution or company been used in
the conception or development of the invention? (e.g. have materials been received from colleagues at
NCSU or at another institution; have you received a request to sign a Material Transfer Agreement, etc.)

Yes
 No
If Yes, please include the following:
Description of Material or Information: ______________________________________________________
Company or University providing the Material or Information: ___________________________________
23. If response to Question (22) was yes, has a Material Transfer Agreement/ Confidentiality Agreement (or
License, Purchase or any other Agreement) been signed?
 Yes
 No
If Yes, please list all Agreements that apply:__________________________________________________
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Invention Disclosure Form – Final Checklist
(for inventors, department heads, and deans)
a)
Have all potential inventors been listed on the first page(s) of the form? Please note that inventorship
differs greatly from authorship. Inventorship is determined by U.S. Patent Law and may apply to anyone
who contributed to the conception of the invention as described in the disclosure, including refinements or
improvements that were essential to the success of the invention. Any employee (including technicians) or
student (graduate and undergraduate) can be an inventor – inventorship is NOT limited to faculty or to EPA
employees.
b) Have all of the inventors signed the disclosure in blue ink on the last page of the form?
c)
Have the appropriate department head(s) and dean(s) also signed the disclosure in blue ink?
d) Has a funding source(s) been indicated for question 20? At least one funding source MUST be indicated.
If nothing else, the source of funds for the inventor’s salary should be listed. If the research was funded by
a federal agency, even if the research is outside the scope of the relevant grant proposal, that federal
funding MUST be indicated.
e)
Have the relevant NCSU account numbers been provided for the funding source(s), at the bottom of the
same question 20?
f)
Has the variety been described in sufficient detail to allow a technical review by the Breeders Release
Board and the NCSU Intellectual Property Committee (Question 7)?
g) Has there been sales or commercial distribution of this variety more than one year prior to the date the plant
variety disclosure form was submitted?
h) Has every question on the invention disclosure form been answered? Please note that responses to all
questions are required. If the answer is not known or is not applicable, please indicate that on the form.
i)
Have all additional pages attached to the disclosure been marked “Confidential”?
j)
For questions 22 and 23, inventors should check “yes” if they’ve received materials from colleagues at
NCSU (especially if they are not listed as inventors on page 1 of the form) or from another institution
which were used in the development of this variety. They should also check “yes” if they have received a
request to fill out a material transfer agreement from any other organization (university or company).
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SIGNATURE OF INVENTOR(S)*
(All signatures should be in BLUE ink)
(date)
(date)
(date)
(date)
Disclosed and Understood by me:
(witness)
(date)
(witness)
(date)
(witness)
(date))
(witness)
(date)
(witness)
(date)
Department Authorization:
Department Head/Center Director
College Dean/Associate Dean for Research
Disclosures must be submitted with original signatures to NCARS
Photocopied signatures will not be accepted
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Please fill and submit this data sheet ONLY if you are submitting a disclosure to NCARS and OTT for
the first time OR if your contact information has changed since you last submitted a disclosure.
CONFIDENTIAL
NCSU File No.
North Carolina State University
Office of Technology Transfer
Box 8210 – 2401Research Drive, Suite 1122, Raleigh, NC 27695-8210
(919) 515-7199  FAX (919) 515-3773
INVENTOR DATA SHEET
Dr./Ms./Mr.
Inventor’s Name:
(First, Middle, Last)
SSN#
NCSU Employee?
Title:
Email:
yes
/
no
_______
Department:
Business/
Campus Address:
Mailing/
Home Address:
Phone: (
)
FAX: (
)
Phone: (
)
Citizenship:
Date:
_______
Please note: If any of the above data changes, you must provide updated information to the Office of
Technology Transfer.
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