LAMBERT & LAMBERT, INC

Invention Licensing and Technology Transfer Phone: 651-552-0080

7616 Currell Blvd., Suite 200, St. Paul, MN 55125-2290 FAX: 651-552-7678

INVENTION SUBMISSION FORM

Please sign and date the “Confidentiality Agreement” and complete the “Invention Submission Form” below. Include payment of $179 by writing a personal check or including your credit card information in the space provided. Mail all information to: Lambert & Lambert, 7616 Currell Blvd., Suite 200, St. Paul, MN 55125-2290.

Inventor Contact Information

Name ____________________________________ Phone ___________________________

Address1 ____________________________________ Fax ___________________________

Address2 ____________________________________ E-mail ___________________________

City/State/Zip____________________________________ Country __________________________

Payment Method

Check Credit Card: MasterCard Visa Discover AMEX

Credit Card Number _________________________________ Expiration ______ / ______

Name on Card _________________________________ Signed ________________________

Status of Invention

Product Research and Development

- Are there drawings available? ________Yes ________No

- Is there a prototype available? ________Yes ________No

Current Proprietary Position

- Have you filed a patent application? ________Yes ________No

- Has a patent been granted? ________Yes ________No

If so, patent number here: _______________________

Marketing and Licensing Efforts

- Have you made any efforts to market or license your

invention, either on your own or with any other ________Yes ________No

organization or agency? If so, please explain below.

________________________________________________________________________________________

LAMBERT & LAMBERT, INC.

Invention Licensing and Technology Transfer

Invention Description

In the space provided below, or by attaching a document, please describe your invention. Please include how it works, the problem that it seeks to solve, and why it is better than existing products on the market.