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CONFIDENTIAL
DATE OF ENFORCEMENT: 01/09/2008 Page 1 of 4 UPDATED VERSION: MAY 2016
BORANG IPR – RIBU/B3/2016/CR
RESEARCH INNOVATION BUSINESS UNIT (RIBU) UiTM-MTDC Technopreneur Centre Universiti Teknologi MARA 40450 Shah Alam Selangor Darul Ehsan Tel : 03 5544 2748 | 5543 7976 / 8577 Faks : 03-5544 2790 Email: [email protected]
INTELLECTUAL PROPERTY RIGHT (IPR) COPYRIGHT APPLICATION FORM
You are encouraged to read on IPR through the website: http://www.myipo.gov.my before submitting your application.
CHECKLIST (IMPORTANT) Note: The completed form must be submitted together with the following documents:
NO: DOCUMENTS ATTACHMENT (√) 1. A copy of the researcher/author/inventor and members (if any)
identification card/MyKad 2. Information about product 3. A copy of a CD (if involving software/program) 4. Pamphlet/Brochure about the invention/work/product (not compulsory) 5. Drawing/photograph of the invention/work/product (if applicable)
SECTION A: APPLICANT INFORMATION
1. Researcher Information (Project Leader):
Name: Staff ID:
Faculty/Campus/ Office No: Institute:
Mobile No: Address:
Fax No:
Email:
Position : Prof. Assoc. Prof. Lecturer Others *Please specify ……………………
For Office Use Only:
Date of application received:
Submission No:
Remarks:
CONFIDENTIAL
DATE OF ENFORCEMENT: 01/09/2008 Page 2 of 4 UPDATED VERSION: MAY 2016
BORANG IPR – RIBU/B3/2016/CR
2. Research Team Members: (Please include Project Leader)(Add Attachment if more than 7 members)
No. Name Staff / Student ID
Contact No. ID/ Passport Number Email Faculty/ Campus/ Institute
% *Contribution
1.
2.
3.
4.
5.
6.
7.
TOTAL 100%
*This will determine the percentage of profit sharing from commercialization activities for this Intellectual Property (IP). (If any)
CONFIDENTIAL
DATE OF ENFORCEMENT: 01/09/2008 Page 3 of 4 UPDATED VERSION: MAY 2016
BORANG IPR – RIBU/B3/2016/CR 3. CoRe Areas. Please tick [√] Green Technology & Sustainable Development
Health & Wellbeing
Management Science
Advanced Computing & Communication
Pharmaceutical & Life Science
Frontier Materials & Industry Application
Humanities, Design & Creativity
Others *Please specify
4. Source of Fund. Please tick [√]
Grant / Fund Resources Amount Granted (RM)
Project Duration Year Start Year End
Research Cluster Fund (DANA RMI)
Research Intensive Faculty (DANA Kecemerlangan)
Science Fund
LRGS
PRGS
ERGS
FRGS
Others *Please specify
No grant / fund resources
-
CONFIDENTIAL
DATE OF ENFORCEMENT: 01/09/2008 Page 4 of 4 UPDATED VERSION: MAY 2016
BORANG IPR – RIBU/B3/2016/CR SECTION B: COPYRIGHT INFORMATION 1. Name or Title of works/creation/publication.
2. Commencement date of works/creation/publication. [ / / ]
3. Completion date of works/creation/publication. [ / / ] 4. Level: National International
Country
5. Date of first disclosure or published (if applicable). [ / / ]
6. Name of Publisher/ Journal/ Others (refer No. 5 above):
7. Description of works/creation/publication. Provide attachment if necessary.
8. Stage of development
Completed Ready to be commercialized Others, please specify.
I/We hereby declare that all the information above is accurate, and I/we understand that RIBU has the right to reject this application if the information is discovered to be false/inaccurate/incomplete. ……………………………………………………. ……………………………. Signature Date
