Thank you for your interest in the technology transfer activities of the U.S. Public Health Service. Your answers to the following questions will provide the foundation for licensing decisions. Please return this form and the required attachments to: Technology Transfer Office, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mailstop K79, Atlanta, GA 30341. 

Identification of Inventions(s) For Which License is Sought (Complete all relevant sections) 

U.S. Patent Application(s) Serial Number(s), Filing Date(s), and Patent Number(s) (if issued): 

Title of Patent Application(s): 

Biological Material(s): 

Inventor(s): 

Source from which you learned of availability of a license to the present invention(s): 

Information About Applicant 

1. Name & Address of Applicant: 

2. Name, title, address, phone and FAX numbers of Applicant's licensing representative: 

3. Is Applicant a U.S. Corporation? _____ yes _____ no 

If no, state country of origin: ________________________________________ 

State of incorporation or citizenship (if an individual):
________________________________________ 

4. Is Applicant a Small Business Firm? _____ yes _____ no 

Type of License Sought 

_____ Exclusive Commercialization License _____ Coexclusive Commercialization License 

_____ Nonexclusive Commercialization License _____ Nonexclusive Internal Commercial Use

License 

(internal use only—no right to sell or otherwise distribute materials) 

______ Commercial Evaluation License _____ Nonexclusive Biological Materials License 

(for a limited-term evaluation) (for materials not covered under a patent or patent application) 

Proposed Field(s) of Use: 

ON SEPARATE ATTACHMENTS TO THIS APPLICATION, PLEASE PROVIDE THE FOLLOWING INFORMATION: 

I. Description of Applicant 

Include nature and type of applicant's business; number of employees; corporate/divisional
commitment to R&D, production, sales & marketing; financial resources; products or services successfully commercialized and any unique capabilities of your company relative to the licensed technology. (If a prior license application has been submitted to the Technology Transfer Office within the past year, you may reference that application for the company description.) 

II. Other Licenses and Use of the Invention 

Identify any licenses previously granted to the Applicant under federally owned inventions. Also, identify, to the best of Applicant's knowledge, the extent to which the invention for which a license is sought is being practiced by private industry or Government, or is otherwise available commercially. 

III. Proposed License Terms 

Include definitions of licensed products, processes or methods; geographic territories; duration of license; claims (if known) of patent/patent application under which the proposed licensed technology would fall; and other terms for which you wish to make a proposal at this time. 

IV. Research, Development and Marketing Plan 

Include description of product(s) or method(s) to be developed with the licensed technology and, for each product or method to be developed, a description of expected product research and development programs, including (where relevant) major preclinical, clinical, regulatory, manufacturing and marketing stages; monetary and personnel commitments for each development stage; and the projected time to accomplish each stage of commercial development. If you will be using the licensed technology in house but will not be directly commercializing the licensed technology or providing a service based on the technology, you need only describe the research program in which the licensed technology will be utilized. 

V. Market Analysis 

Include relevant market segment(s) the licensed technology will serve when commercialized; market size and projected growth of relevant markets during the duration of the license; estimated market share once product is introduced; and sales projections based on market share analysis. (THIS INFORMATION NEED NOT BE PROVIDED IN APPLICATIONS FOR COMMERCIAL EVALUATION LICENSES OR NONEXCLUSIVE COMMERCIAL RESEARCH LICENSES.) 

VI. Other Information Which You Believe Will Support a Determination to Grant the Requested License 

VII. For Applicants for Exclusive or Partially Exclusive Licenses ONLY 

A detailed statement as to 1) why Federal and public interests will be best served by exclusive licensing of this invention; 2) why expeditious practical application of the invention is unlikely to occur under a nonexclusive license; 3) why the exclusive licensing of this invention is a reasonable and necessary incentive to attract investments of risk capital; 4) why the exclusive licensing of this invention will not tend substantially to lessen competition or result in undue market concentration; and 5) why the proposed license terms and scope of exclusivity are not greater than reasonably necessary. 

I certify, to the best of my knowledge, that all of the information provided on this application
and on attachments to this application is true and accurate. 

___________________________________________________________________
________________ 

Signature of Applicant or Authorized Representative     Date 

___________________________________________________________________ 

Print Name and Title 

The commercial and financial responses in this application will be treated as privileged and
confidential information as provided in 15 U.S.C. 209(a); and, to the extent permitted by law, will not be accessible under the Freedom of Information Act.