1. Inventors
  2. Inventor Certification

Inventor Certification

Having been listed as an inventor on the Technology Disclosure titled below, please complete, digitally sign and submit this form to complete your portion of the Technology Disclosure. The Technology Disclosure is not fully complete until ALL inventors listed have filled out, digitally signed and submitted this Form. 

 

Technology Details

Personal Information
Please provide the following information; if the fields have been pre-populated for you, please verify they are correct.
Inventor's Name
Please provide your full legal name.
Employer Information
Please provide the name of the employer in which you are employed or assigned during this invention.
Please indicate the name of the Primary School by which you were employed or assigned at the time of invention. If the Primary School is not in the list please select "Other..." and type in the name in the field provided.
Please indicate the name of the Department by which you were employed or primarily assigned at the time of invention. If the Department is not listed please select "Other..." and type in the name in the field provided.
Please indicate the name of the Department by which you were employed or assigned at the time of Invention. If the Department is not in the list please select "Other..." and type in the name in the field provided.
Please indicate the name of the Division by which you were employed or assigned at the time of invention. If the Division is not in the list please select Other... and type in the name in the field provided.
Centers and Institutes
Hold down the control (ctrl) button (command for Mac) to select multiple options.
Veterans Affairs (VA)
Contact Information
Home Address
Please provide your current address by first selecting the country.
Country of Citizenship
Disclosure Information

If you need to view the Disclosure, click here

If you need a copy of the Disclosure, please e-mail cttc.disclosures@vanderbilt.edu to request a copy.

Assignment Information
Inventors
Signature Terms

For good and valuable consideration, as set forth in the Policy on Technology and Literary and Artistic Works in the Vanderbilt University Faculty Manual and, as applicable, the Policy on Technology and Literary and Artistic Works in the Vanderbilt University Medical Center Employment Manual (links to each policy provided below for convenience), as such policies may be amended from time to time, the sufficiency and adequacy of which are hereby acknowledged:

  • I agree to assign and hereby do assign, sell, and transfer unto VANDERBILT UNIVERSITY my entire right, title and interest in and to any invention(s), software, creative work(s), or material(s) disclosed herein and related thereto, including but not limited to any associated intellectual property rights.
  • I hereby agree to execute without further consideration any and all applications, petitions, oaths and assignments or other papers and instruments which may be necessary in order to carry into full force and effect, the sale, assignment, transfer and conveyance hereby made or intended to be made.
  • I hereby agree that no assignment, sale, agreement or encumbrance has been or will be made or entered into by me that would conflict with this assignment.
  • I have read and reviewed the information contained in the Disclosure Form and this Assignment of Rights and agree that to the best of my knowledge, all information, including contributor information and royalty sharing allocation, is acceptable and accurate.