Invention Disclosure

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Inventor's Name *
Mailing Address *
City:
State or Country:
Zip:
Home telephone number:
Daytime telephone number:
Email: *
Short Title of Your Invention:
Purpose of Your Invention:
General Description of Your Invention (basic concept including main components):
 
Sketch: Please draw a rough sketch of invention on the reverse side of this page or on a separate sheet(s) and attach it to this sheet.
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