Technology Evaluation Form

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1. Please generally describe your device.

2. Does the device require input of energy to begin functioning? If so, how much and for how long?

3. If any input is required, what is the source of the energy (battery, capacitor, wall outlet etc? How much wattage (power) is required? (Please read the criteria carefully. The device must be closed -loop.)

4. What amount of energy output does your device create (in full watts, not milliwatts)?

5. How did you measure the input and output? Please be specific.

6. What is the ratio of input to output (That is, how many times over unity is it?)?

7. Do you have other partners or investors who must give permission for you to have the device tested and made available open source to the public? Did you develop this technology with someone else? Who?

8. Do you have an inventor’s notebook or other evidence of the date of conception and a record of the development of the device?

9. Have you applied for or been granted a patent? When? What patent number? Who was the patent attorney?

10. Are you willing to have the prototype tested transparently (that is, no black boxes) at other facilities?

11. Are there any hazardous, radioactive, rare or very expensive components? Please list and please review the criteria.

12. Will you bring the technology with plans to the Charlottesville VA area to be tested and reproduced from the plans you supply?

13. Do you have any questions for us?

Name

First

Last

Full Address

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Land Line Number (including area code)

Mobile Number (including area code)

Website (if applicable)

Statement of Truth / Confirmation:

I attest that this information is complete and is true to the best of my knowledge. I agree to the criteria described.

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