Republic of the Philippines

Sorsogon State University

Sorsogon City
Tel. No. (056) 211 0178 – 211 0200; ip@sorsu.edu.ph

(Date)

________________
University President
Sorsogon State University
Sorsogon City

Attn: VPRET

Madam:

I/We would like to pursue IPR application of our technology generated from our research
entitled
(Title of Research)

Attached are the following requirements for further evaluation:

 Technology Disclosure Form

 Preliminary Search Report
 Confidentiality Disclosure Agreement
 Drawing/s of the Technology (if any)
 Test Results (if any)
 Technical report/Thesis/ Completed Research paper

Thank you.

Very truly yours, Endorsed by:

Campus Administrator/ Dean

Advanced Education

Republic of the Philippines

 Sorsogon State University
Sorsogon City
Tel. No. (056) 211 0178 – 211 0200; ip@sorsu.edu.ph

CONFIDENTIALITY DISCLOSURE AGREEMENT

We hereby acknowledge and agree to the following terms and conditions:

• “Confidential Information” shall mean any and all information, know-how and data, technical or non-
technical, and information relating to the Technology, disclosed by parties, whether disclosed or
provided in oral, written, graphic, photographic or any form.

• To keep secret and confidential all Confidential Information acquired during submission of the
documents disclosed electronically, orally or in writing.

• We will not, except as required or permitted by law, either throughout the duration of review and
evaluation of the documents or at any time afterwards, divulge any Confidential Information to
any third party; nor will I make use of such information other than in the proper, authorized
performance of the task assigned. In particular, I will not use Confidential Information in a
manner prejudicial or detrimental to the interest of the Disclosing Party.

• We will not publish any literature, deliver any lecture or make any communication with the press, media
or other such third party relating to the Confidential Information, unless I have the written permission of
the Disclosing Party.

• We will not take photographs, make sketches or otherwise reproduce or copy details of Confidential
Information unless I have written permission from the Disclosing Party.

• Unless otherwise specified in writing, all Confidential Subject Matter remains the Disclosing Party’s
property.

• We agree that the Disclosing Party may take legal proceedings against me if I am in breach of any of the
undertakings set out above.

• We acknowledge that this CDA shall be governed by Philippine laws.

• We acknowledge that this CDA shall come into force upon signing and shall remain in force for the
duration review and evaluation of the documents and shall remain in force thereafter for one
year, or until a patent or UM application is filed for the Technology, whichever comes sooner.

Name of Researcher/s Address University/Institution Date Signature

 Republic of the Philippines
Sorsogon State University
Sorsogon City
Tel. No. (056) 211 0178 – 211 0200; ip@sorsu.edu.ph

TECHNOLOGY DISCLOSURE FORM

Please do your best to complete as much of this form as possible. Incomplete technology/invention submissions may delay the IP application.
Add spaces and/or table rows as needed. If a question does not apply, please mark "N/A". If for any reason the information you need to add
does not fit within the boxes, please feel free to add information as an attachment as necessary. For advice on completing this
technology/disclosure or for additional information, contact the IP office personnel. Upon completion of the technology/invention disclosure
form, all supporting documentation must be attached.

1. Title of Invention:
2. Chronology of Invention
a. When the invention was conceived and reduced to practice

Date Location and Comments

Idea First Conceived
Experimental Evidence of
Invention
First Written Description

b. Past Disclosure: (Public Disclosure of the Invention prior to filling up this disclosure)

Name of Activity Date

c. Future Disclosure. Specify the planned date of disclosure.

Name of Activity Date

3. Provide a Non-confidential, Simple and Commercially Applicable Summary of the Invention

4. Detailed Description of the Invention: (If necessary, additional descriptive information may be added as an appendix (e.g. data charts,
graphs, publications, abstracts, grant applications, presentations, etc).

5. What Are the Practical and Commercial Applications of the Invention?

(e.g. what problem does it solve?)

6. What Are the Advantages of Your Invention Over Currently Available Technologies?
(e.g. what technology is currently used to meet this need and how is your technology better?)
7. Funding Sources

Funding Source Name of Department/Agency Grant Number

8. Did This Invention Utilize Outside Sources of Materials or Confidential Information:

(Please list all agreements (e.g. MTA, CDA, consulting, contracts, etc) involved in conception and development of the invention.)

Source Information Type of Agreement and Date

9. Please List any Companies You Find Are/Might Be Interested in Your Invention.
(Specific contacts are most helpful).

Name of Company Contact Information

10. List any known pre-existing technology which your invention derives from, integrates or
otherwise would be required to utilize.

11. Inventor Identification: Please include all potential inventors, including collaborators from other institutions outside SSC. (We will
consult with the Primary Contact on whether and how best to contact any outside potential inventors.)

Name Contact No. Email Campus/ Designation Signature

Add Department

Republic of the Philippines

Sorsogon State University
Sorsogon City
Tel. No. (056) 211 0178 – 211 0200; ip@sorsu.edu.ph

PRELIMINARY SEARCH REPORT

About the Technology
Tentative Title:

Short Description of the Technology

Agency Affiliation:
Inventors
Date Search report was made
Keywords

Results of Preliminary Search

Database Keywords No. of Hits
USPTO

WIPO/Patentscope

Espacenet

IPOPHIL

Google Patent

Closest Technology (from the search made, cite at least one):

Advantage(s) from the closest technology:

I declare that the above information is true and correct to the best of my knowledge.

________________________
Signature over Printed Name