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Biological Material Disclosure Form - CONFIDENTIAL Please see the last page of this document for submission instructions. 1. Title: Please provide a non-confidential title for the material. 2. Description: Please describe your material, including those aspects which make it unique from other materials. Please include data showing that the material works. If any part of your material is described in a manuscript, published paper or presentation, copies of all such material must be provided in addition to this description.3. What are the practical and commercial applications of the material? (example: what problem does it solve?)4. What are the advantages of the material over currently available materials?5. Please provide the storage location of the material: (i.e. institution, campus, building, room & freezer, etc.)6. Have you shared the material with others? ____ YES____ NOIf YES, please list the names of individuals and entities that currently have the material in their possession and details. 7. Proprietary materials, data or confidential information: Did the creation of the material use proprietary materials, data or confidential information from the corporate sector, government agencies or other labs (within or outside the University of Nebraska) to develop this material? Proprietary materials include, but are not limited to: antibodies, cell lines, vectors, genes, research animals, knock-out or transgenic mice, equipment, computer code and open source software. ____ YES____ NO ____ UNSURE of Proprietary StatusPlease list all agreements relating to any proprietary materials or confidential information.Type of Agreement(e.g., material transfer, confidential disclosure, consulting, sponsored research)Parties to the Agreement8. Funding sources: Have researchers received any funding for this material, including funding for salaries? Sources of funding include, but are not limited to, support from federal or other government agencies, corporate sponsors, private/public foundations, research centers, university/departmental funding (including startup funds), etc.ATTENTION: All funding sources must be disclosed in this section because sponsors may have intellectual property rights through federal law or University contracts.____ YES____ NOPlease list all sources of funding below:Name of Agency, Company or DepartmentGrant / WBS NumberDo any researchers have an IANR-ARD (Hatch, Hatch Multi-State, McIntire-Stennis or Animal Health) project that relates to this material?____ YES____ NOIf YES, please provide all Nebraska Agricultural Experiment Station project numbers (i.e. NEB-31-124):9. Regardless of sponsorship, is any of the disclosed information subject to export or publication controls?____ YES____ NO_____UNSUREIf YES, please provide additional information.10. Please list any companies that might be interested in licensing the material. (Specific contacts are most helpful).Company NameContact NameContact Information11. List of Researchers: Please list all potential researchers who contributed to the conception of the technology. This is an extremely important section, as listing the incorrect researchers may result in the invalidation of a patent. If you are unsure whether someone contributed to the conception of the technology, please list them and NUtech will assist in determining the proper listing of researchers. Please also describe each potential researcher’s involvement with regard to this technology. (Please copy and paste “Additional Researchers” section as needed.)Primary Contact:Preferred Title: ____ Dr. ____ Mr. ____ Ms. Other: ____________________ Male Female Please indicate: Prefer not to answerFull Name:Title:Dept./Affiliation:Office Address:Office Phone:Office Email:Citizenship:Home Address:Home Phone:Home Email: UNL Researcher Non-UNL ResearcherDo you hold an appointment with any school or campus in addition to UNL?____ Yes____ No If yes, please provide additional information:Describe your contribution with regard to this technology:Additional Researchers:Preferred Title: ____ Dr. ____ Mr. ____ Ms. Other: ____________________ Male Female Please indicate: Prefer not to answerFull Name:Title:Dept./Affiliation:Office Address:Office Phone:Office Email:Citizenship:Home Address:Home Phone:Home Email:____ UNL Researcher __ __ Non-UNL ResearcherDo you hold an appointment with any school or campus in addition to UNL?____ Yes____ No If yes, please provide additional information:Describe your contribution with regard to this technology:Signature(s) of UNL Researchers: (Duplicate signature blocks as necessary.)To the best of my knowledge all statements and information provided in this disclosure form are true and complete. I confirm that all sources of funding related to this technology have been included in this form. I understand and agree that all rights, obligations and financial interests pertaining to or derived from the technology are as determined under the University of Nebraska Board of Regents and University of Nebraska Bylaws and Policies, including, but not limited to Bylaw 3.10, Policy 4.4.1, Policy 4.4.2, and UNL Royalty and Equity Distribution Policy 7001. I also understand and agree that the Policies may change from time to time, including the percentage of net royalties paid to me by NUtech Ventures, which are currently derived only from consideration in the form of money or equity received by NUtech Ventures under a license, option, or material transfer agreement for licensed rights. I agree to assist NUtech Ventures in the evaluation, possible copyrighting or patenting and commercialization of any technology described in this form.All potential researchers affiliated with the University of Nebraska during the conception of any element of the technology must sign below. By signing this disclosure form you hereby confirm your assignment, for good and valuable consideration, the sufficiency of which is hereby agreed, and assign to the Board of Regents of the University of Nebraska and its successors and assigns, all intellectual and tangible property rights, titles and interests in and to this technology including, without limitation, the right to sue for and retain damages relating to past, present and future infringement thereof and the right to priority.Date: ___________________Signature: ____________________________________Printed Name: _________________________________Date: ___________________Signature: ____________________________________Printed Name: _________________________________Signature(s) of Non-UNL Researchers: (Duplicate signature blocks as necessary.)To the best of my knowledge all statements and information provided in this disclosure form are true and complete. Date: ___________________Signature: ____________________________________Printed Name:_________________________________Date: ___________________Signature: ____________________________________Printed Name:_________________________________Submission of Disclosure to NUtech VenturesThank you for disclosing your technology to NUtech Ventures, a technology commercialization affiliate of the University of Nebraska, serving the Lincoln and Kearney campuses. NUtech Ventures evaluates, protects, markets and licenses the university’s intellectual property to improve quality of life and promote economic development. This disclosure form is the first step in a process that could potentially lead to commercialization of your technology. Completion of this form is very important and assists NUtech Ventures in multiple ways:This form acts as a written, dated record of your technology.It also provides NUtech Ventures with the information needed to determine the notification requirements of any organization(s) that funded your work related to your technology.It provides NUtech Ventures with the basic information necessary to evaluate your technology for patentability and commercial viability.It is important that you provide the most comprehensive and complete disclosure form possible so that NUtech Ventures can make an informed decision on whether or not to protect the technology. Please attach additional pages and documents as necessary. Submit your completed disclosure form (in Word format), along with any supporting documentation, electronically to Stacy Kroeger at HYPERLINK "mailto:skroeger@" skroeger@.After you submit the disclosure, our office will review the disclosure for accuracy and completeness. Once the disclosure is accepted, it will be sent to each researcher for electronic signature via DocuSign (if your initial submission was not signed by all of the University of Nebraska researchers). A technology manager will be assigned to your technology and will contact you to arrange a meeting. The purpose of this meeting is to discuss NUtech's evaluation process and gain a more comprehensive understanding of the technology. The technology manager will then work with you to determine and define next steps. ................
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