RECORD OF INVENTION
BE IT KNOWN
THAT___________________________________________________________
Residing
at_____________________________________________________________________
City____________________________________________State________________Zip________
Home
Phone _________________________ Business
Phone_______________________________
has conceived the invention illustrated and described within this RECORD
OF INVENTION document which is called
_____________________________________________________________________________
_____________________________________________________________________________
and
has this __________________________day of_____________________2002 disclosed
to
us this invention and we understand its construction and use.
Witness_____________________________________Witness__________________________________
Date of original conception of
idea__________________________________________________
Date first disclosed
idea to others___________________________________________________
Date
sketches were first
made______________________________________________________
Working Model ( ) has
( ) has not (check one) been made.
Has a
patent search been made?
________________When?_______________________________
What did search reveal
in relation to existing
patents?______________________________________
______________________________________________________________________________
Are
any particular molds or tools needed to make your
invention?_____________________________
______________________________________________________________________________
| State of
________________ County of ________________ |
I,__________________________________________________________________ (Type or Print Your Name) being duly sworn, upon oath depose and state that I believe myself to be the original, first and sole inventor of the device described herein, and that all dates and statements made herein are true to the best of my knowledge and belief. ___________________________________________________________________ Sworn and subscribed before me This_____________________ day of_________________________19___________ Notary
Public_________________________________________________________ |