Area of Description of INVENTION,






















Area of any Sketches of INVENTION,

















Inventors name                                   READ AND UNDERSTOOD BY:


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         Signature of Inventor               Signature of Witness

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         Date Signed                             Date Signed

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         Print Name of Inventor            Print Name of Witness

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         Street or P.O. Box No.              Street or P.O. Box No.

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         City, State & Zip Code             City, State & Zip Code

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         Phone Number                       Phone Number