Be It known that I (we)_____________________________________________________________

Residing at________________________________________________________________________

Business Phone: ______________________

Home Phone: __________________________

Email: ______________________________________

have invented certain new and useful improvements in (Name of the Invention)

as fully described and illustrated hereinafter.

I (we) first conceived the idea:____________________________________________________

I (we) made my (our) first sketch and description:____________________________________

I (we) made my (our) first model (if any):__________________________________________

Signature________________________________________________

Signature________________________________________________

Be it known that________________________________________________________________

has this day____________________of_____________20___disclosed to me (us) the invention which is described and illustrated in the Record of Invention Form.
He (she) calls his (her) invention_____________________________________________________ and I (we) fully understand its construction, purpose and use.
(Do not use members of the family or relatives as witnesses.)

I, Joseph H. McGlynn, agree that the details of your idea, invention, or product which are submitted with this Record of Invention shall not be sold, assigned, or disclosed to any other person, organization or corporation unless agreed to by both parties in a subsequent agreement.

It is understood that I assume no responsibility with respect to features of the invention which can be demonstrated to be already known to me.