Technology Evaluation Form

Please ll out in detail. Use another sheet if necessary. 1. Please generally describe your device.

2. Does the device require input of energy to begin functioning? If so, how much and for how long?

3. If any input is required, what is the source of the energy (battery, capacitor, wall outlet etc? How much wattage (power) is required? (Please read the criteria carefully. The device must be closed -loop.)

4. What amount of energy output does your device create (in full watts, not milliwatts)?

5. How did you measure the input and output? Please be specic.

6. What is the ratio of input to output (That is, how many times over unity is it?)?

7. Do you have other partners or investors who must give permission for you to have the device tested and made available open source to the public? Did you develop this technology with someone else? Who?

8. Do you have an inventors notebook or other evidence of the date of conception and a record of the development of the device?

9. Have you applied for or been granted a patent? When? What patent number? Who was the patent attorney?

10. Are you willing to have the prototype tested transparently (that is, no black boxes) at other facilities?

11. Are there any hazardous, radioactive, rare or very expensive components? Please list and please review the criteria.

12. Will you bring the technology with plans to the Charlottesville VA area to be tested and reproduced from the plans you supply?

13. Do you have any questions for us?

14. Enter your contact information REQUIRED (Name , address, land line, cell phone , email, website (if applicable)

The application must be signed before being submitted.

I attest that this application is complete and that the information included is true to the best of my knowledge. I agree to the rules of the Award and the criteria above. Signature:

Name printed:

Date:

Please print out criteria and technology application and scan completed forms to: energy.MikeSchrum@gmail.com

There is no one available to take phone calls or answer emails about the criteria. We can only respond to completed signed application forms.