RECIPIENT

Contact Details

Intellectual Property Title

Type of intellectual property and intellectual property protection (e.g. patent, design registration, plant breeders right registration, copyrighted Work (specify))

Application / Registration No. (where applicable)

INTELLECTUAL PROPERTY CREATOR(S)

First Name

Middle Name(s)

Family Name

Country / Territory (where applicable application filed or registered)

Status of intellectual property protection (for example, granted, application, non-registered)

Date of reporting of intellectual property to NIPMO (please attach copy)

Funding Agency (i.e. the funding agency that funded the conception or development of the intellectual property)

Summary description of the intellectual property and intellectual property protection

Explanation of why assignment is necessary for commercialisation of the intellectual property

Explanation of why the intellectual property cannot be commercialised through means other than assignment to a third party, such as through exclusive licensing

 
 
Details of proposed assignee

Full Name

Registration Number of Assignee

Business Address

Country of Domicile

How the public interest will be served by assignment including, for example: