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

Summary details of type exclusivity (i) field of use; (ii) territory

Explanation of why the intellectual property cannot be commercialised through non-exclusive licensing

Full details of proposed exclusive licensee (include registration number; country of domicile)

Compliance with regulations 12(6) and 12(7). In particular, must substantiate public benefit and any retention of rights to the intellectual property in South Africa

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

Detail alternative commercialisation of intellectual property if this application is not approved. Please substantiate.