+---------------------+---------------+------------+---+-------------+
| 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          |               |            | T |             |
| Licensing Program,  |               |            | C |             |
| U.S. Department of  |               |            | A |             |
| Agriculture,        |               |            | S |             |
| Agricultural        |               |            | E |             |
| Research            |               |            | N |             |
|                     |               |            | O |             |
| Service, 5601       |               |            | . |             |
| Sunnyside Ave.; Rm  |               |            |   |             |
| 4-1159, Beltsville, |               |            | ( |             |
| MD 20705-5131       |               |            | * |             |
|                     |               |            | O |             |
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+---------------------+---------------+------------+---+-------------+
| 6\. TITLE OF        |               |            | 4 |             |
| PATENT/PATENT       |               |            | \ |             |
| APPLICATION         |               |            | . |             |
|                     |               |            | U |             |
|                     |               |            | . |             |
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+---------------------+---------------+------------+---+-------------+
| 7\. SOURCE OF       |               |            | 5 |             |
| INFORMATION         |               |            | \ |             |
| CONCERNING          |               |            | . |             |
| AVAILABILITY OF     |               |            | T |             |
| THIS INVENTION      |               |            | Y |             |
|                     |               |            | P |             |
|                     |               |            | E |             |
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+---------------------+---------------+------------+---+-------------+
| 8\. NAME AND        |               | 9\. NAME   |   |             |
| ADDRESS OF          |               | AND        |   |             |
| APPLICANT           |               | ADDRESS OF |   |             |
|                     |               | REPR       |   |             |
|                     |               | ESENTATIVE |   |             |
|                     |               | TO WHOM    |   |             |
|                     |               |            |   |             |
|                     |               | CORR       |   |             |
|                     |               | ESPONDENCE |   |             |
|                     |               | 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 OF  |            |   | DATE        |
| made for a license  | APPLICANT or  |            |   |             |
| to practice in the  | AUTHORIZED    |            |   |             |
| United States, the  | R             |            |   |             |
| Government-owned    | EPRESENTATIVE |            |   |             |
| invention           |               |            |   |             |
| identified herein,  |               |            |   |             |
| in accordance with  |               |            |   |             |
| 35 USC 208          |               |            |   |             |
+---------------------+---------------+------------+---+-------------+