Patent Application Form

PATENT APPLICATION FORM

This Patent Application Form is executed by Applicant Name: , Applicant Address: and Agent/Representative Name: , Representative Firm: (collectively, the Parties).

RECITALS

WHEREAS, Applicant is the owner or assignee of certain rights in an invention described below and desires to file a patent application to secure patent rights in the United States and/or other jurisdictions; and

WHEREAS, Representative is duly authorized to prepare, file and prosecute patent applications on behalf of Applicant and to represent Applicant before patent authorities; and

WHEREAS, the Parties desire to set forth the information, declarations and authorizations necessary to initiate and prosecute the patent application identified herein.

NOW, THEREFORE

In consideration of the mutual covenants and agreements contained herein, the Parties agree as follows:

1. APPLICATION DETAILS

Provisional    Non-provisional    International (PCT)    Other:

2. INVENTORS

Provide full legal name and contact information for each inventor. Add additional inventor pages if necessary.

3. APPLICANT / ASSIGNEE

Entity Type:    Individual    Corporation    LLC    Other:

4. PRIORITY CLAIMS

If priority is claimed from an earlier application, provide the following for each claim.

5. ABSTRACT

6. SPECIFICATION / DESCRIPTION

7. CLAIMS

8. DRAWINGS

9. DECLARATION AND OATH

The undersigned inventor(s) declare under penalty of perjury that: (a) the information in this application is true and correct to the best of their knowledge; (b) they believe themselves to be the original inventor(s) of the subject matter which is claimed; and (c) they acknowledge that making a false statement may expose the declarant to penalties under applicable law.

Each inventor hereby appoints Representative to act as attorney or agent to prosecute the application, to sign and execute all papers on behalf of the inventor in connection with the application, and to receive correspondence concerning the application.

Authorization to File: By checking this box, Applicant authorizes Representative to file the application as specified herein and to take all actions reasonably necessary to prosecute the application.

10. FEES AND PAYMENT

Applicant acknowledges responsibility for payment of all official filing, search and examination fees, and agrees to reimburse Representative for any advance payments made on Applicant's behalf.

Payment Method:    Check    Wire Transfer    Credit Card

11. REPRESENTATIONS AND WARRANTIES

Applicant represents and warrants that Applicant has the full legal right and authority to file the application and to assign rights in the invention to or through Applicant as necessary. Applicant further warrants that no third party has rights that would prevent the filing or grant of the patent, except as disclosed in writing to Representative.

12. NOTICES

13. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Form and the obligations created by it shall be governed by and construed in accordance with the laws of the jurisdiction where the Applicant is domiciled, without regard to conflicts of law principles. This Form contains the entire agreement of the Parties with respect to the subject matter hereof, and supersedes all prior and contemporaneous agreements and understandings, whether written or oral. If any provision of this Form is held invalid or unenforceable, that provision shall be severed and the remaining provisions shall remain in full force and effect.

14. AMENDMENTS; WAIVER; COUNTERPARTS

This Form may be amended only by a written instrument signed by both Parties. Failure by either Party to enforce any provision of this Form shall not constitute a waiver of that provision. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

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