Testimonial of Invention

This Testimonial of Invention form is an important record of your invention.

Name___________________________________________________________________
Address_________________________________________________________________
City______________________________________State_________Zip Code__________
Telephone (

)_____________________________

Has conceived the invention described and illustrated in this form

Named as:_______________________________________________________________
On this________________day of____________20_________

Witness_________________________________________________________________
1. Describe the idea:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. Describe how it works:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3. What makes this idea unique?:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4. Who would use this invention?:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Sketch of Invention

DECLARATIO

I, ____________________________________________________________, being duly

(Print ame)
sworn upon oath, depose and state that I believe myself to be the original, first and
sole inventor of the device described herein, and that all dates and statements made
in this document are true to the best of my knowledge and belief.

_____________________________________________________
Signature