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Information required for Certification of Invention (example)

I, ___James Jones____________________, hereby certify that the invention of the ___left-handed yardstick_____________________________, patent application # _xxxxx________, was made by me on (date) __June 31, 1901___________________, while employed at the VA Medical Center, (location) _Palo Alto, CA_______, as (title of position) __Biomedical Engineer__________________________.

The other inventor(s) was/were:

Role and contribution

___Lucy Arnaz, VA, Biomedical Engineer______

___Contributed to initial concept______

___Lou LuBelle, Consultant_________________

___Participated in designing product___

The invention was made:

1. During official working hours yes __x__ no _____

2. With the contribution by the VA of
a. Facilities
b. Equipment
c. Materials
d. Funds
e. Information
f. My time or services while on duty
g. Time or services of other VA employees on duty
 yes __x__ no _____
yes __x__ no _____
yes __x__ no _____
yes __x__ no _____
yes __x__ no _____
yes __x__ no _____
yes __x__ no _____
3. The invention
a. bears a direct relation to my duties
b. was made in consequence of my duties
yes __x__ no _____
yes __x__ no _____
4. Remarks are attached to this statement. yes __x__ no _____


Signature ___________________________________

Present Title
___________________________________

Home Address
___________________________________


     Investigator
 Transfer Officer
 Center Director


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