Office Docket #: ____________
SOFTWARE DISCLOSURE FORM
Confidential
For Use by Office of Research Partnerships and Commercialization
Please fill out the form below completely, sign it, and email it to [email protected]. If you have
any questions, please contact her at 862-0123.
1. TITLE OF SOFTWARE: CLICK HERE TO ENTER TEXT.
2. DESCRIPTION OF THE SOFTWARE
A. What was the problem you set out to solve and who do you envision as potential users? CLICK HERE
TO ENTER TEXT.
B. What is new and novel about your Software solution (advantages & special characteristics)? CLICK
HERE TO ENTER TEXT.
C. Describe any experimental work that proves your Software is effective. Identify specific test data,
models or products created. CLICK HERE TO ENTER TEXT.
D. Are there limitations to your Software? Are you continuing work to overcome these limitations? Click
here to enter text.
E. What additional, but not yet developed, features are you working on or could envision in your
Software?Are there limitations to your Software? Click here to enter text.
F. Please attach any additional materials to explain your Software, such as documentation,
presentations, applications.
3. SOFTWARE RECORD
A. Please provide a date when the Software development began and when it was completed. CLICK
HERE TO ENTER TEXT.
B. What hardware configurations or operating systems are required to use the Software? CLICK HERE TO
ENTER TEXT.
C. What commercial utilities or applications were/are required? CLICK HERE TO ENTER TEXT.
D. What programming language(s) were used to develop the Software? CLICK HERE TO ENTER TEXT.
E. Please identify the Software and provide the license if you have used open source or free Software
other than Software created by innovators/authors while they worked at UNH. CLICK HERE TO ENTER
TEXT.
F. If the Software is a small component or function of a greater body of code, what is the purpose of that
component or function? CLICK HERE TO ENTER TEXT.
G. If the Software is owned or authored by third party sources, please identify them. CLICK HERE TO
ENTER TEXT.
4. PUBLIC OR PRIVATE DISCLOSURE RECORD
A. Has the Software or source code has been disclosed in an abstract, manuscript, conference
document, conference presentation, conversation, news story, or thesis? CLICK HERE TO ENTER TEXT.
If yes, please provide:
 The date: CLICK HERE TO ENTER TEXT.
 Form/format of disclosure: CLICK HERE TO ENTER TEXT.
 A copy or details
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Updated 6/8/2012
B. Do you plan to have a publication or other disclosure in the next six months? CLICK HERE TO ENTER
TEXT.
If yes, please provide:
 The predicted date: CLICK HERE TO ENTER TEXT.
 Form/format of disclosure: CLICK HERE TO ENTER TEXT.
 A copy of drafts, preprints, etc.
C. Have you disclosed your innovation to industry representatives? CLICK HERE TO ENTER TEXT.
If yes, please provide
 The name of the company: CLICK HERE TO ENTER TEXT.
 The company representative’s: CLICK HERE TO ENTER TEXT.
 Name: CLICK HERE TO ENTER TEXT.
 Email: CLICK HERE TO ENTER TEXT.
 Phone number: CLICK HERE TO ENTER TEXT.
D. Has there been any sale, offer of sale, commercial testing or public use of the innovation? CLICK HERE
TO ENTER TEXT.
If yes, please provide the sale, testing or use
 The date of sale: CLICK HERE TO ENTER TEXT.
 Form/format of disclosure: CLICK HERE TO ENTER TEXT.
 A copy or details:
5. SPONSORSHIP/FUNDING
A. Was the research that led to the invention sponsored? CLICK HERE TO ENTER TEXT.
If yes, please attach a copy of the contract or agreement and provide:
 Sponsor Name: CLICK HERE TO ENTER TEXT.
 Agreement/Contract #: CLICK HERE TO ENTER TEXT.
 UNH Grant & Contract Administrator: CLICK HERE TO ENTER TEXT.
6. COMMERCIALIZATION
A. How does your Software compare to what is currently available in commercial products? CLICK HERE
TO ENTER TEXT.
B. If anyone has expressed interest in licensing your Software, please describe your discussions, contacts
and any proposed licensing terms. CLICK HERE TO ENTER TEXT.
C. Please provide any information that may be valuable in realizing the full commercial potential of the
Software such as applications, promotion, marketing or distribution. CLICK HERE TO ENTER TEXT.
D. If the Software developers have any financial interest in the proposed licensee organization (including
investment, income, or as position as owner, director, officer, trustee, or employee), please describe in
detail the economic Interest. CLICK HERE TO ENTER TEXT.
E. Please provide non-proprietary description and key words that we can use to market your Software.
CLICK HERE TO ENTER TEXT.
F. Please estimate the level of customization and/or support the Software will need once licensed. CLICK
HERE TO ENTER TEXT.
7. KEY CONTACT
A. Who should the Office contact for routine communications?
 Name: CLICK HERE TO ENTER TEXT.
 Email: CLICK HERE TO ENTER TEXT.
8. INNOVATOR(s) and SIGNATURE(s)
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The signature lines below MUST be signed. The date of the last signature is the date when this
disclosure comes into effect. List the names and titles of all inventors and identify their % contribution.
The contribution of all inventors should total 100%. The Lead Inventor contributes the highest %.
Name: CLICK HERE TO ENTER TEXT.
% Contribution CLICK HERE TO ENTER TEXT.
Title: CLICK HERE TO ENTER TEXT.
Department: CLICK HERE TO ENTER TEXT.
College/School: CLICK HERE TO ENTER TEXT.
University (if other than UNH): CLICK HERE TO ENTER TEXT.
Home Address: CLICK HERE TO ENTER TEXT.
E-Mail Address: CLICK HERE TO ENTER TEXT.
Citizenship: CLICK HERE TO ENTER TEXT.
If not US Citizen, please provide Alien registration number and expiration date
Signature: ___________________________________ Date: ______________
(click to add more)
If you anticipate that there could be a patent, trademark and/or copyright that in some way relates to
this Software, please submit the specific ORPC disclosure form.
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