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| My Name: |
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| Address: |
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| E-mail: |
(this e-mail address will be used to send you a copy of this form) |
| Work Tel: |
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| Home Tel: |
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I am less than 18 years old
I am at least 18 years old |
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Agfa may use my idea freely. I neither expect nor seek compensation
If Agfa uses my idea I hope to receive compensation |
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| Name or Title of my Idea : |
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Description of my idea
Complete but do not include any confidential or proprietary information describing your invention here. |
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| My invention can be briefly described as
follows: |
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I have sent to you non-confidential informaion on this idea
I am enclosing non-confidential information on this idea
I am sending under cover non-confidential information on this idea |
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| This information is in the form of: |
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patent application with serial number and filing date : |
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written descriptions
photographs, drawings or sketches
other |
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| If your idea involves literary material, please fill out the following: |
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| 1. Has your literary material ever been published? |
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Yes
No |
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| 2. Was a copyright notice included in the publications? |
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Yes
No |
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| 3. Did you obtain a copyright registration certificate? |
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Yes
No |
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| Name and address of present employer: |
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| Name and address of employer when you first got the idea: |
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| Does any of the employers have any right to the idea? |
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Yes
No |
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| List the names, addresses and interests of others having any rights to this idea: (if none, write 'none') |
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| I have read the Agfa Guidelines and agree to all the conditions set forth. I understand that the above description of my product and the answers to the accompanying questions are furnished on a Non-Confidential and Unrestricted basis. Agfa may retain the information submitted herewith. |
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| Questionnaire |
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| Please answer to the following questions to the best of your ability without divulging any confidential information. This information will help us promptly determine whether Agfa is interested on your idea. |
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| 1. Does your idea involve a product, a process, a service, or more than one of these? |
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| 2. What does your product, process or service do? (not how does it do it) |
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| 3. Is your idea designed for sale to the public or for internal Agfa use? |
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| 4. In general, what market area does your idea apply to? |
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| 5. Does your idea replace or improve an existing product, process or service, or is it completely new? |
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| 6. Can any existing product or process perform a similar function, althought not as well? If so, please identify the existing product or process and briefly state why your idea is better. |
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| 7. Does your idea include a consumable item? If so, how long can it be used before its life expectancy expires? |
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| 8. Would additional research work by Agfa be necessary to commercialize your idea? If 'yes', please indicate how much time, and money would reasonably be required to reach the commercial stage? |
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| 9. Have you constructed an operational prototype? If so, can we have access to it later? |
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10. If your idea is for a product:
a) what is the estimated manufacturing cost?
b) what is the estimated selling price for the product?
c) how large do you think the market is for your product? |
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| 11. Please state patent status by ticking the relevant box and providing relevant additional details. |
No patent protection sought
Patent application was filed
on (date)
in country
patent granted as No.
in country
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| 12. Are exclusive rights to the product available? |
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I understand that the information I have disclosed herein is NON-CONFIDENTIAL. I will retain a copy of this, and everything I send you.
Please print this file now. |
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