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Private Data Stamp: Yes X: 5" Y: -1.10"
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Witnessed & Understood byDate


Submitter(s) Signature(s)Date

NOTE: Each attached page of additional description must be signed, dated and witnessed.

XEROXrInvention Proposal

To:Xerox Patent Department

1Xerox Square - 020, Rochester, N.Y. 146441El Segundo, Calif., 701 S. Aviation Blvd. 90245
XPalo Alto, Calif., 3333 Coyote Hill Road 943041Dallas, Texas, 1341 W. Mockingbird Lane 75247

(Send Original to your Patent Department location above, and copy your Manager)

Proposal Submitted By (Please use legal name) First, Middle, LastEmployee No.

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1Organization (Unit/Div./Dept./Sec.)Location/Bldg.Extension

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Proposal Submitted By (Please use legal name) First, Middle, LastEmployee No.

2Organization (Unit/Div./Dept./Sec.)Location/Bldg.Extension

Proposal Submitted By (Please use legal name) First, Middle, LastEmployee No.

*3Organization (Unit/Div./Dept./Sec.)Location/Bldg.Extension

*If space for additional submitter is required, please use another sheet.

ManagerProgram and/or Technology

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Descriptive Title of Proposal

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Names of Others Known to have Worked on this same Technology

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Description of Idea

(It is helpful to include background information on area of utility and existing problems, followed by description of idea, with drawings where possible, and discussion of where the new idea improves over present technology. It is permissible to attach copies of materials such as lab notebook pages, memos, drawings, etc. and refer to such items in the body of the invention proposal. All such materials should be signed and dated by the inventor(s) and witnessed.)

INSTRUCTIONS: You can start typing the text of your Invention Proposal by selecting this paragraph. It is set up with 2 pt. leading between lines (X 2) and 8 pt. leading between paragraphs (Y 8).