This form serves as a formal petition for university support for innovations covered under Section II of the Southern Illinois University- System Intellectual Property Policy (SIU IP Policy) for Board affiliates only. Per the SIU IP Policy, Board affiliates are defined as developers who desire their innovation to be supported by the university, but who are not automatically obligated by the SIU IP Policy to assign their rights in the innovation to the Board of Trustees of Southern Illinois University. Board affiliates include, but are not limited to, medical residents, unpaid adjunct professors, unpaid students, and students who have not used substantial university funding or resources to develop the innovation. Board affiliates are required to complete this petition for any innovation they wish to be supported by the university.

SECTION 1: INNOVATION TITLE

SECTION 2: DEVELOPER INFORMATION/SIGNATURES

Provide the requested information for each Board affiliate that made (or may have made) an intellectual contribution to the technology. Use copies of page 2 of this petition as needed to add additional Board affiliates. By signing this petition, the Board affiliate identified below hereby petitions the Board of Trustees of Southern Illinois University for university support of the above referenced innovation.

If this petition is approved, the Board affiliate identified below will be treated as a developer obligated to assign his/her intellectual property ownership rights to the Board of Trustees of Southern Illinois University as defined by the SIU IP Policy. The Board affiliate must complete a corresponding Evaluation Request Form to assign the innovation referenced above to the Board so that it may be governed by the SIU IP Policy. *Note that the title and developer information should match the associated Office of Technology Transfer Evaluation Request Form.

Signature:	Date:
Name (Board affiliate):	Title:
SIU Department or Outside Company/Organization:
Work Phone Number:	Work Email Address:
Home Address (Street, City, State, and Zip Code):
Role/Contribution:	Country of Residence:

SECTION 3: INSTITUTIONAL ACKNOWLEDGEMENT (FOR OTT USE ONLY)

This Evaluation Request Petition is:	Approved	Denied

OTT File Identifier:	Date Received by OTT:
Signature, Senior Research Administrator:	Date:

SECTION 2 (CONTINUED): ADDITIONAL DEVELOPER INFORMATION/SIGNATURES

Provide the requested information for each additional Board affiliate that made (or may have made) an intellectual contribution to the technology. By signing this petition, each Board affiliate identified below hereby petitions the Board of Trustees of Southern Illinois University for university support of the above referenced innovation.

If this petition is approved, each Board affiliate identified below will be treated as a developer obligated to assign his/her intellectual property ownership rights to the Board of Trustees of Southern Illinois University as defined by the SIU IP Policy. Board affiliates must complete a corresponding Evaluation Request Form to assign the innovation referenced above to the Board so that it may be governed by the SIU IP Policy. *Note that the title and developer information should match the associated Office of Technology Transfer Evaluation Request Form.

Signature:	Date:
Name (Board affiliate):	Title:
SIU Department or Outside Company/Organization:
Work Phone Number:	Work Email Address:
Home Address (Street, City, State, and Zip Code):
Role/Contribution:	Country of Residence:

Signature:	Date:
Name (Board affiliate):	Title:
SIU Department or Outside Company/Organization:
Work Phone Number:	Work Email Address:
Home Address (Street, City, State, and Zip Code):
Role/Contribution:	Country of Residence:

Signature:	Date:
Name (Board affiliate):	Title:
SIU Department or Outside Company/Organization:
Work Phone Number:	Work Email Address:
Home Address (Street, City, State, and Zip Code):
Role/Contribution:	Country of Residence:

Signature:	Date:
Name (Board affiliate):	Title:
SIU Department or Outside Company/Organization:
Work Phone Number:	Work Email Address:
Home Address (Street, City, State, and Zip Code):
Role/Contribution:	Country of Residence: