+-----------------------+-------------+--------------+---+--------------+
| United States         |             |              | 1 |              |
| Department of         |             |              | \ |              |
| Agriculture           |             |              | . |              |
|                       |             |              | A |              |
| **PATENT LICENSE      |             |              | g |              |
| APPLICATION**         |             |              | e |              |
|                       |             |              | n |              |
| **FOR GOVERNMENT      |             |              | c |              |
| INVENTION**           |             |              | y |              |
|                       |             |              | P |              |
| Submit an original    |             |              | a |              |
| form to --            |             |              | t |              |
|                       |             |              | e |              |
| Coordinator,          |             |              | n |              |
| Technology Licensing  |             |              | t |              |
| Program, U.S.         |             |              | C |              |
| Department of         |             |              | a |              |
| Agriculture,          |             |              | s |              |
| Agricultural Research |             |              | e |              |
|                       |             |              | N |              |
| Service, 5601         |             |              | o |              |
| Sunnyside Ave.; Rm    |             |              | . |              |
| 4-1159, Beltsville,   |             |              | ( |              |
| MD 20705-5131         |             |              | * |              |
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+-----------------------+-------------+--------------+---+--------------+
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+-----------------------+-------------+--------------+---+--------------+
| 6\. TITLE OF          |             |              | 4 |              |
| PATENT/PATENT         |             |              | \ |              |
| APPLICATION           |             |              | . |              |
|                       |             |              | U |              |
|                       |             |              | . |              |
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+-----------------------+-------------+--------------+---+--------------+
| 7\. SOURCE OF         |             |              | 5 |              |
| INFORMATION           |             |              | \ |              |
| CONCERNING            |             |              | . |              |
| AVAILABILITY OF THIS  |             |              | T |              |
| INVENTION             |             |              | Y |              |
|                       |             |              | P |              |
|                       |             |              | E |              |
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+-----------------------+-------------+--------------+---+--------------+
| 8\. NAME AND ADDRESS  |             | 9\. NAME AND |   |              |
| OF APPLICANT          |             | ADDRESS OF   |   |              |
|                       |             | RE           |   |              |
|                       |             | PRESENTATIVE |   |              |
|                       |             | TO WHOM      |   |              |
|                       |             | CO           |   |              |
|                       |             | RRESPONDENCE |   |              |
|                       |             | SHOULD BE    |   |              |
|                       |             | ADDRESSED    |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 10\. STATE OF         |             | 11\.         |   |              |
| INCORPORATION (if     |             | TELEPHONE,   |   |              |
| corporation) or       |             | FAX, AND     |   |              |
| CITIZENSHIP (if an    |             | EMAIL        |   |              |
| individual)           |             |              |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 12\. NATURE AND       |             |              |   |              |
| DESCRIPTION OF        |             |              |   |              |
| APPLICANT'S BUSINESS  |             |              |   |              |
| -- Identify products  |             |              |   |              |
| or services           |             |              |   |              |
| successfully          |             |              |   |              |
| commercialized.       |             |              |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 13\. APPROXIMATE      |             | 14\. IS      |   |              |
| NUMBER OF EMPLOYEES   |             | APPLICANT A  |   |              |
|                       |             | SMALL        |   |              |
|                       |             | BUSINESS     |   |              |
|                       |             | CONCERN?     |   |              |
|                       |             |              |   |              |
|                       |             | YES NO       |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 15\. FIELD(S) OF USE  |             |              |   |              |
| IN WHICH APPLICANT    |             |              |   |              |
| INTENDS TO PRACTICE   |             |              |   |              |
| INVENTION             |             |              |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 16\. IS APPLICANT     |             |              |   |              |
| WILLING TO ACCEPT A   |             |              |   |              |
| LICENSE FOR LESS THAN |             |              |   |              |
| ALL FIELDS OF USE AS  |             |              |   |              |
| INDICATED IN ITEM 15  |             |              |   |              |
| ABOVE?                |             |              |   |              |
|                       |             |              |   |              |
| YES NO                |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 17\. SPECIAL TERMS OR |             |              |   |              |
| CONDITIONS OF LICENSE |             |              |   |              |
| DESIRED               |             |              |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 18\. APPLICANT'S BEST |             |              |   |              |
| KNOWLEDGE OF EXTENT   |             |              |   |              |
| TO WHICH THE          |             |              |   |              |
| INVENTION IS BEING    |             |              |   |              |
| PRACTICED BY PRIVATE  |             |              |   |              |
| INDUSTRY AND/OR       |             |              |   |              |
| GOVERNMENT, OR IS     |             |              |   |              |
| OTHERWISE AVAILABLE   |             |              |   |              |
| COMMERCIALLY          |             |              |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 19\. GEOGRAPHIC AREAS |             |              |   |              |
| IN WHICH APPLICANT    |             |              |   |              |
| INTENDS TO MAKE, USE, |             |              |   |              |
| AND/OR SELL THIS      |             |              |   |              |
| INVENTION             |             |              |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 20\. DETAILED         |             |              |   |              |
| DESCRIPTION OF        |             |              |   |              |
| DEVELOPMENT AND/OR    |             |              |   |              |
| MARKETING FOR EACH    |             |              |   |              |
| FIELD OF USE TO WHICH |             |              |   |              |
| RIGHTS ARE SOUGHT     |             |              |   |              |
|                       |             |              |   |              |
| (**PLEASE REVIEW      |             |              |   |              |
| INSTRUCTIONS**)       |             |              |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 21\. ADDITIONAL       |             |              |   |              |
| INFORMATION TO        |             |              |   |              |
| SUPPORT APPLICATION   |             |              |   |              |
|                       |             |              |   |              |
|                       |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+
| 22\. *Application is  | SIGNATURE   |              |   | DATE         |
| made for a license to | OF          |              |   |              |
| practice in the       | APPLICANT   |              |   |              |
| United States, the    | or          |              |   |              |
| Government-owned      | AUTHORIZED  |              |   |              |
| invention identified  | REP         |              |   |              |
| herein, in accordance | RESENTATIVE |              |   |              |
| with 35 USC 208.*     |             |              |   |              |
+-----------------------+-------------+--------------+---+--------------+