Document:

Chang of Control Agreement - Anton Monk

 Exhibit 10.17 
 CHANGE OF CONTROL AGREEMENT 
 This Change of Control Agreement (the “Agreement”) is made
effective as of January 19, 2005 between Entropic Communications, Inc. (“Entropic”), and Anton Monk (“Employee”), subject to the approval of the Entropic Board of Directors. 
 RECITALS 
 Employee is presently
employed as the Vice President of Engineering for Entropic. Employee and Entropic desire to memorialize in writing their understanding regarding severance payments and vesting of options in the event of a Change of Control. Employee and Entropic
acknowledge that this Agreement constitutes the entire agreement between the parties relating to severance benefits upon change of control and supersedes any and all other agreements, either oral or in writing, between Employee and Entropic and all
other subsidiaries or affiliates of Entropic with respect to the matters discussed herein. 
 AGREEMENT 
 In consideration of the promises and of the mutual covenants contained herein, and for other good and valuable consideration, receipt of which is hereby
acknowledged, the parties do hereby agree as follows: 
 1. Effect of Certain Terminations after Change in Control. 
 1.1 Severance Package. If within one (1) year after a Change of Control (as that term is defined below) Employee’s employment is
terminated without “Cause,” or Employee resigns for good “Reason,” then Entropic will provide Employee with the following “Severance Package,” provided Employee complies with the conditions set forth in section I.2
below: (i) Employee will receive a severance payment equal to six (6) months of Employee’s base salary, payable in accordance with Entropic’s normal payroll practices; (ii) six (6) months of COBRA coverage paid by the
Company; and (iii) accelerated vesting of fifty percent (50%) options granted to Employee under Entropic’s stock option plans that, as of the date of such termination without Cause or voluntary resignation for Good Reason, remain
unvested, to the extent permissible by law. The acceleration of vesting provision set forth in this section 1.1 is notwithstanding and in addition to any existing vesting provisions set forth in Entropic’s stock option plans. 
 1.2 Conditions to Receive Severance Package. The Severance Package described above will be paid provided Employee meets the following conditions:
(a) Employee complies with all surviving provisions of any confidentiality or proprietary rights agreement signed by Employee; and (b) Employee executes a full general release, in a form acceptable to Entropic* releasing all claims, known
or unknown, that Employee may have against Entropic, and any subsidiary or related entity, their officers, directors, employees and agents, arising out of or any way related to Employee’s employment or termination of employment with Entropic.

 1.3 280G. Notwithstanding section 1 .I above, if it is determined that the amounts payable to Employee under this Agreement, when
considered together . with any other amounts payable to Employee as a result of a Change in Control (collectively, the “Payment”) would (i) constitute a “parachute payment” within the—meaning of Section 280G of the
Internal Revenue Code of 1986, as amended (the “Code”), and (ii) but for this sentence, be subject to the excise tax imposed by Section 4999 of the Code (the “Excise Tax”), then such Payment 

 
shall be equal to the Reduced Amount. The “Reduced Amount” shall be either (x) the largest portion of the Payment that would result in no
portion of the Payment being subject to the Excise Tax or (y) the largest portion, up to and including the total, of the Payment, whichever amount, after taking into account all applicable federal, state and local employment taxes, income
taxes, and the Excise Tax (all computed at the highest applicable marginal rate), results in Employee’s receipt, on an after-tax basis, of the greater amount of the Payment notwithstanding that all or some portion of the Payment may be subject
to the Excise Tax. If a reduction in payments or benefits constituting “parachute payments” is necessary so that the Payment equals the Reduced Amount, reduction shall occur in the following order unless Employee elects in writing a
different order (provided, however, that such election shall be subject to Company approval if made on or after the effective date of the event that: triggers the Payment): reduction of cash payments; reduction of accelerated vesting of stock
options; reduction of employee benefits. In the event that acceleration of vesting of stock option compensation is to be reduced, such acceleration of vesting shall be cancelled in the reverse order of the date of grant of Employee’s stock
options (i.e. earliest granted stock option cancelled last) unless Employee elects in writing a different order for cancellation. 
 The
accounting firm engaged by Entropic for general audit purposes as of the day prior to the effective date of the Change in Control shall perform the foregoing calculations. If the accounting firm so engaged by Entropic is serving as accountant or
auditor for the individual, entity or group effecting the Change in Control, Entropic shall appoint a nationally recognized accounting firm to make the determinations required hereunder. Entropic shall bear all expenses with respect to the
determinations by such accounting firm required to be made hereunder. 
 The accounting firm engaged to make the determinations hereunder
shall provide its calculations, together with detailed supporting documentation, to Employee and Entropic within fifteen (j5) calendar days after the date on which Employee’s right to a Payment is triggered (if requested at that time by
Employee or Entropic) or such other time as requested by Employee or Entropic. If the accounting firm determines that no Excise Tax is payable with respect to a Payment, either before or after the application of the Reduced Amount, it shall furnish
Employee and Entropic with an opinion reasonably acceptable to Employee that no Excise Tax will be imposed with respect to such Payment. Any good faith determinations of the accounting firm made hereunder shall be final, binding and conclusive upon
Employee and Entropic, except as set forth below. 
 If, notwithstanding any reduction described in this Section 1.3, the IRS determines
that Employee is liable for the Excise Tax as a result of the receipt of the Payment of benefits as described above, then Employee shall be obligated to pay back to Entropic, within thirty (30) days after a final IRS determination or in the
event that Employee challenges the final IRS determination, a final judicial determination, a . portion of the payment equal to the “Repayment Amount.” The Repayment Amount with respect to the payment of benefits shall be the smallest such
amount, if any, as—shall be required to be paid to Entropic so that Employee’s net after-tax proceeds with respect to any payment of benefits (after taking into account the payment of the Excise Tax and all other applicable taxes imposed
on such payment) shall be maximized. The Repayment Amount with respect to the payment of benefits shall be zero if a Repayment Amount of more than zero would not result in Employee’s net after-tax proceeds with respect to the payment of such
benefits being maximized. If the Excise Tax is not eliminated pursuant to this paragraph, Employee shall pay the Excise Tax. 

 Notwithstanding any other provision of this Section 1.3, if (i) there is a reduction in the
payment of benefits as described in this section, (ii) the IRS later determines that Employee is liable for the Excise Tax, the payment of which would result in the maximization of Employee’s net after-tax proceeds (calculated as if
Employee’s benefits had not previously been reduced), and (iii) Employee pays the Excise Tax, then Entropic shall pay to Employee those benefits which were reduced pursuant to this section contemporaneously or as soon as administratively
possible after Employee pays the Excise Tax so that Employee’s net after-tax proceeds with respect to the payment of benefits is maximized. 
 1.4 Change in Control. A “Change in Control” means: (i) the direct or indirectly state or exchange in a single or series of related transactions by the stockholders of Entropic of more than fifty percent (50%) of
the voting stock of Entropic; (ii) a merger or consolidation in which Entropic is a party after which the stockholders of Entropic immediately prior to such transaction hold less than fifty percent (.50%) of the voting securities of the
surviving entity; (iii) the sale, exchange, or transfer of all or substantially all of the assets of Entropic after which the stockholders of Entropic immediately prior to such transaction hold less than fifty percent (50%) of the voting
securities of the corporation or other business entity to which the assets of Entropic were transferred; or (iv) a liquidation or dissolution of Entropic. 
 1.5 Termination for “Cause.” For purposes of this Agreement, a termination for “Cause” occurs if Employee is terminated for any of the following reasons: (i) conviction of, or plea of
nolo contendere to, a felony; (ii) theft or embezzlement, or attempted theft or embezzlement, of money or property or assets of the Company; (iii) termination consistent with the provisions and procedures of the Company’s drug policy;
(iv) continued neglect of your duties in connection with your employment by the Company (not due to a physical or mental illness), which continues for at least ten (1 0) days after written notice of demand for compliance is delivered to you by
the Company, which demand identifies the manner in which the Company believes that you have not performed such duties and the steps required to cure such failure to perform; or (v) intentional and willful engagement in misconduct which is
materially injurious to the Company. 
 Notwithstanding the foregoing clause (iv), Employee may not be terminated for Cause as a result of
his failure or inability to perform assigned duties which are substantially inconsistent with his duties and responsibilities in effect during the year preceding the Change in Control (or such shorter period of time as Employee was employed by
Entropic). 
 Notwithstanding the foregoing clauses, your employment shall not be deemed to be terminated for Cause, and no other action
shall be taken by the Company which is adverse to you hereunder unless and until there shall have been delivered to you a copy of a statement of the basis for Cause, signed and approved by an officer of the Company. 
 1.6 Voluntary Resignation for “Good Reason.” After a Change in Control, Employee may terminate Employee’s employment with Entropic
for “Good Reason” by serving notice of resignation to Entropic with a description of the circumstances giving rise to the Good Reason. For purposes of this Agreement, “Good Reason” means: (a) the assignment to Employee of
any duties, or any limitation of Employee’s responsibilities, substantially inconsistent with his positions, duties, responsibilities and status with Entropic immediately prior to the date of the Change of Control, (b) the relocation of
the principal place of Employee’s service with Entropic to a location that is more than fifty (50) miles from Employee’s principal place of service with Entropic immediately prior to the date of the Change of Control,
(c) any material reduction by Entropic of Employee’s base salary in effect immediately prior to the date 

 
of the Change of Control (unless reductions comparable in amount and duration are concurrently made for all other employees of Entropic with
responsibilities, organizational level and title comparable to Employee) or (iv) any failure by Entropic to continue to provide Employee with the opportunity to participate in any benefit or compensation plans and programs in which Employee was
participating immediately prior to the date of the Change of Control, or their equivalent. 
 1.7 Payment Upon Death or Disability.
Neither death nor disability shall affect Entropic’s obligations hereunder, provided however that neither death nor disability shall be deemed to be Cause and death or disability shall be Good Reason under this agreement. 
 2. At-Will Employment. Employee acknowledges that Employee continues as an at-will employee and agrees that nothing in this Agreement is intended
to or should be construed to contradict, modify or alter Employee’s at-will employment relationship with Entropic. 
 3. No Other
Severance Benefits. Employee acknowledges and agrees that the Severance Package provided pursuant to this Agreement is in lieu of any other severance benefits to which Employee may be eligible under any other agreement and/or Entropic severance
plan or practice. 
 4. General Provisions. 
 4.1 Severability. If any provision of this Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remaining provisions shall nevertheless continue in full force without
being impaired or invalidated in any way. 
 4.2 Successors and Assigns. The rights and obligations of Entropic under this Agreement
shall inure to the benefit of and shall be binding upon the , successors and assigns of Entropic. Employee shall not be entitled to assign any of his rights or obligations under this Agreement, other than to his estate as provided in section 1.7.

 4.3 Applicable Law. This Agreement shall be interpreted, construed, governed and enforced in accordance with the laws of the United
States of America and the State of California. Each of the parties irrevocably consents to the exclusive jurisdiction of the federal and state courts located in San Diego, California, as applicable, for any matter arising out of or relating to this
Agreement. 
 4.4 Amendments. No amendment or modification of the terms-or conditions of this Agreement shall be valid unless in
subsequent writing and signed by the parties thereto. 

 IN WITNESS WHEREOF, the parties hereto execute this Agreement, effective as of the date first above
written. 
  

									
	EMPLOYEE:	 		 	ENTROPIC COMMUNICATIONS, INC.
				
	 /s/ Anton Monk
	 		 	By:	 	 /s/ Illegible

	Name:	 	Anton Monk	 		 	Title:	 	Director of Finance, Assistant Secretary
	Address:	 	 5706 Willowmere Ln
 San Diego, CA 92130
	 		 	Address:	 	 9276 Scranton Road, Ste. 200
 San Diego, California
92121Form of Employee Innovations

 Exhibit 10.18 
 

 
 EMPLOYEE INNOVATIONS AND PROPRIETARY RIGHTS 
 ASSIGNMENT AGREEMENT 
 This Agreement is intended to formalize in writing
certain understandings and procedures which have been in effect since the time I was initially employed by Entropic Communications, Inc. (“Company”). In return for my new or continued employment by Company and other good and
valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I acknowledge and agree that: 
 1. Prior Work. All
previous work done by me for Company relating in any way to the conception, reduction to practice, creation, derivation, design, development, manufacture, sale or support of products or services for Company is the property of Company, and I hereby
assign to Company all of my right, title and interest in and to such previous work. 
 2. Proprietary Information. My employment
creates a relationship of confidence and trust between Company and me with respect to any information: 
 (a) Applicable to the business of
Company; or 
 (b) Applicable to the business of any client or customer of Company, which may be made known to me by Company or by any client
or customer of Company, or learned by me in such context during the period of my employment. 
 All such information has commercial value in the business in
which Company is engaged and is hereinafter called “Proprietary Information.” By way of illustration, but not limitation, Proprietary Information includes any and all technical and non-technical information including patent,
copyright, trade secret, and proprietary information, techniques, sketches, drawings, models, inventions, know-how, processes, apparatus, equipment, algorithms, software programs, software source documents, and formulae related to the current,
future and proposed products and services of Company, and includes, without limitation, respective information concerning research, experimental work, development, design details and specifications, engineering, financial information, procurement
requirements, purchasing manufacturing, customer lists, business forecasts, sales and merchandising and marketing plans and information. “Proprietary Information” also includes proprietary or confidential information of any third party who
may disclose such information to Company or to me in the course of Company’s business. 
 3. Ownership and Nondisclosure of
Proprietary Information. All Proprietary Information is the sole property of Company, Company’s assigns, and Company’s customers, and Company, Company’s assigns and Company’s customers shall be the sole and exclusive owner of
all patents, copyrights, mask works, trade secrets and other rights in the Proprietary Information. I hereby do and will assign to Company all rights, title and interest I may have or acquire in the Proprietary Information. At all times, both during
my employment by Company and after termination of such employment, I will keep in confidence and trust all Proprietary Information, and I will not use or disclose any Proprietary Information or anything directly relating to Proprietary Information
without the written consent of Company, except as may be necessary in the ordinary course of performing my duties as an employee of Company. 
  

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 4. Ownership and Return of Materials. All materials (including, without limitation, documents,
drawings, models, apparatus, sketches, designs, lists, and all other tangible media of expression) furnished to me by Company shall remain the property of Company. Upon termination of my employment, or at any time on the request of Company before
termination, I will promptly (but no later than fifteen (15) days after the earlier of my employment’s termination or Company’s request) destroy or deliver to Company, at Company’s option, (a) all materials furnished to me
by Company, (b) all tangible media of expression which are in my possession and which incorporate any Proprietary Information or otherwise relate to Company’s business, and (c) written certification of my compliance with my
obligations under this sentence. 
 5. Innovations. As used in this Agreement, the term “Innovations” means all
processes, machines, manufactures, compositions of matter, improvements, inventions (whether or not protectable under patent laws), works of authorship, information fixed in any tangible medium of expression (whether or not protectable under
copyright laws), moral rights, mask works, trademarks, trade names, trade dress, trade secrets, know-how, ideas (whether or not protectable under trade secret laws), and all other subject matter protectable under patent, copyright, moral right, mask
work, trademark, trade secret or other laws, and includes without limitation all new or useful art, combinations, discoveries, formulae, manufacturing techniques, technical developments, discoveries, artwork, software, and designs.
“Innovations” includes “Inventions,” which is defined to mean any inventions protected under patent laws. 
 6.
Disclosure of Prior Innovations. I have identified on Exhibit A (“Prior Innovations”) attached hereto all Innovations, applicable to the business of Company or relating in any way to Company’s business or
demonstrably anticipated research and development or business, which were conceived, reduced to practice, created, derived, developed, or made by me prior to my employment with Company (collectively, the “Prior Innovations”), and I
represent that such list is complete. I represent that I have no rights in any such Innovations other than those Prior Innovations specified in Exhibit A (“Prior Innovations”). If there is no such list on Exhibit A
(“Prior Innovations”), I represent that I have neither conceived, reduced to practice, created, derived, developed nor made any such Prior Innovations at the time of signing this Agreement. 
 7. Assignment of Innovations; License of Prior Innovations. I hereby agree promptly to disclose and describe to Company, and I hereby do and will
assign to Company or Company’s designee my entire right, title, and interest in and to, (a) each of the Innovations (including Inventions), and any associated intellectual property rights, which I may solely or jointly conceive, reduce to
practice, create, derive, develop or make during the period of my employment with Company, which either (i) relate, at the time of conception, reduction to practice, creation, derivation, development, or making of such Innovation, to
Company’s business or actual or demonstrably anticipated research or development, or (ii) were developed on any amount of Company’s time or with the use of any of Company’s equipment, supplies, facilities or trade secret
information, or (iii) resulted from any work I performed for Company, and (b) each of the Innovations which is not an Invention (as demonstrated by me by evidence meeting the clear and convincing standard of proof), and any associated
intellectual property 

  

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rights, which I may solely or jointly conceive, develop, reduce to practice, create, derive, develop, or make during the period of my employment with
Company, which are applicable to the business of Company (collectively, the Innovations identified in clauses (a) and (b) are hereinafter the “Company Innovations”). To the extent any of the rights, title and interest in
and to Company Innovations cannot be assigned by me to Company, I hereby grant to Company an exclusive, royalty-free, transferable, irrevocable, worldwide license (with rights to sublicense through multiple tiers of sublicensees) to practice such
non-assignable rights, title and interest. To the extent any of the rights, title and interest in and to Company Innovations can be neither assigned nor licensed by me to Company, I hereby irrevocably waive and agree never to assert such
non-assignable and non-licensable rights, title and interest against Company or any of Company’s successors in interest to such non-assignable and non-licensable rights. I hereby grant to Company or Company’s designees a royalty free,
irrevocable, worldwide license (with rights to sublicense through multiple tiers of sublicensees) to practice all applicable patent, copyright, moral right, mask work, trade secret and other intellectual property rights relating to any Prior
Innovations which I incorporate, or permit to be incorporated, in any Company Innovations. Notwithstanding the foregoing, I agree that I will not incorporate, or permit to be incorporated, any Prior Innovations in any Company Innovations without
Company’s prior written consent. 
 8. Cooperation in Perfecting Rights to Proprietary Information and Innovations. 

(a) I agree to perform, during and after my employment, all acts deemed necessary or desirable by Company to permit and assist Company, at
Company’s expense, in obtaining and enforcing the full benefits, enjoyment, rights and title throughout the world in the Proprietary Information and Innovations assigned or licensed to, or whose rights are irrevocably waived and shall not be
asserted against, Company under this Agreement. Such acts may include, but are not limited to, execution of documents and assistance or cooperation (i) in the filing, prosecution, registration, and memorialization of assignment of any
applicable patents, copyrights, mask work, or other applications, (ii) in the enforcement of any applicable patents, copyrights, mask work, moral rights, trade secrets, or other proprietary rights, and (iii) in other legal proceedings
related to the Proprietary Information or Innovations. 
 (b) In the event that Company is unable for any reason to secure my signature to
any document required to file, prosecute, register, or memorialize the assignment of any patent, copyright, mask work or other applications or to enforce any patent, copyright, mask work, moral right, trade secret or other proprietary right under
any Proprietary Information (including improvements thereof) or any Innovations (including derivative works, improvements, renewals, extensions, continuations, divisionals, continuations in part, continuing patent applications, reissues, and
reexaminations thereof), I hereby irrevocably designate and appoint Company and Company’s duly authorized officers and agents as my agents and attorneys-in-fact to act for and on my behalf and instead of me, (i) to execute, file,
prosecute, register and memorialize the assignment of any such application, (ii) to execute and file any documentation required for such enforcement, and (iii) to do all other lawfully permitted acts to further the filing, prosecution,
registration, memorialization of assignment, issuance, and enforcement of patents, copyrights, mask works, moral rights, trade secrets or other rights under the Proprietary Information, or Innovations, all with the same legal force and effect as if
executed by me. 
  

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 9. No Violation of Rights of Third Parties. My performance of all the terms of this Agreement and
as an employee of Company does not and will not breach any agreement to keep in confidence proprietary information, knowledge or data acquired by me prior to my employment with Company, and I will not disclose to Company, or induce Company to use,
any confidential or proprietary information or material belonging to any previous employer or others. I am not a party to any other agreement which will interfere with my full compliance with this Agreement. I agree not to enter into any agreement,
whether written or oral, in conflict with the provisions of this Agreement. 
 10. Survival. This Agreement (i) shall survive my
employment by Company; (ii) does not in any way restrict my right or the right of Company to terminate my employment at any time, for any reason or for no reason; (iii) inures to the benefit of successors and assigns of Company; and
(iv) is binding upon my heirs and legal representatives. 
 11. Nonassignable Inventions. This Agreement does not apply to an
Invention which qualifies fully as a nonassignable invention under the provisions of Section 2870 of the California Labor Code. I acknowledge that a condition for an Invention to qualify fully as a non-assignable invention under the provisions
of Section 2870 of the California Labor Code is that the invention must be protected under patent laws. I have reviewed the notification in Exhibit B (“Limited Exclusion Notification”) and agree that my signature
acknowledges receipt of the notification. 
 12. No Solicitation. During the term of my employment with Company and for a period of
two (2) years thereafter, I will not solicit, encourage, or cause others to solicit or encourage any employees of Company to terminate their employment with Company. 
 13. Injunctive Relief. A breach of any of the promises or agreements contained herein will result in irreparable and continuing damage to Company for which there will be no adequate remedy at law, and Company
shall be entitled to injunctive relief and/or a decree for specific performance, and such other relief as may be proper (including monetary damages if appropriate). 
 14. Notices. Any notice required or permitted by this Agreement shall be in writing and shall be delivered as follows, with notice deemed given as indicated: (a) by personal delivery, when delivered
personally; (b) by overnight courier, upon written verification of receipt; (c) by telecopy or facsimile transmission, upon acknowledgment of receipt of electronic transmission; or (d) by certified or registered mail, return receipt
requested, upon verification of receipt. Notices to me shall be sent to any address in Company’s records or such other address as I may specify in writing. Notices to Company shall be sent to Company’s Human Resources Department or to such
other address as Company may specify in writing. 
 15. Governing Law. This Agreement shall be governed in all respects by the laws of
the United States of America and by the laws of the State of California, as such laws are applied to agreements entered into and to be performed entirely within California between California residents. Each of the parties irrevocably consents to the
exclusive personal jurisdiction of the 

  

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federal and state courts located in California, as applicable, for any matter arising out of or relating to this Agreement, except that in actions seeking to
enforce any order or any judgment of such federal or state courts located in California, such personal jurisdiction shall be nonexclusive. 
 16. Severability. If any provision of this Agreement is held by a court of law to be illegal, invalid or unenforceable, (i) that provision shall be deemed amended to achieve as nearly as possible the same economic effect as the
original provision, and (ii) the legality, validity and enforceability of the remaining provisions of this Agreement shall not be affected or impaired thereby. 
 17. Waiver; Amendment; Modification. The waiver by Company of a term or provision of this Agreement, or of a breach of any provision of this Agreement by me, shall not be effective unless such waiver is in
writing signed by Company. No waiver by Company of, or consent by Company to, a breach by me, will constitute a waiver of, consent to or excuse of any other or subsequent breach by me. This Agreement may be amended or modified only with the written
consent of both me and Company. No oral waiver, amendment or modification shall be effective under any circumstances whatsoever. 
 18.
Entire Agreement. This Agreement represents my entire understanding with Company with respect to the subject matter of this Agreement and supersedes all previous understandings, written or oral. 
 I certify and acknowledge that I have carefully read all of the provisions of this Agreement and that I understand and will fully and faithfully comply
with such provisions. 
  

									
	 COMPANY:
	 		 	EMPLOYEE:
			
	 Entropic Communications, Inc.
	 		 	
					
	 By:
	 	  
	 		 	By:	 	  

	 Title:
	 	  
	 		 	Printed Name:	 	  

	 Dated:
	 	  
	 		 	Dated:	 	  

  

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 EXHIBIT A 
 Prior Innovations 
  

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 EXHIBIT B 
 Limited Exclusion Notificaiton 
 THIS IS TO NOTIFY you in accordance with Section 2872 of the
California Labor Code that the foregoing Agreement between you and Company does not require you to assign or offer to assign to Company any invention that you developed entirely on your own time without using Company’s equipment, supplies,
facilities or trade secret information except for those inventions that either: 
 1. Relate at the time of conception or reduction to
practice of the invention to Company’s business, or actual or demonstrably anticipated research or development of Company; or 
 2.
Result from any work performed by you for Company. 
 To the extent a provision in the foregoing Agreement purports to require you to assign
an invention otherwise excluded from the preceding paragraph, the provision is against the public policy of this state and is unenforceable. 
 This limited exclusion does not apply to any patent or invention covered by a contract between Company and the United States or any of its agencies requiring full title to such patent or invention to be in the United States. 
 I ACKNOWLEDGE RECEIPT of a copy of this notification. 
  

			
	 By:
	 	  

	
	  

	 (Printed Name of Employee)

		
	 Date:
	 	  

  

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