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-82- [[preprinted form]] SMITHSONIAN INVENTION DISCLOSURE Invention Disclosure Number [[blank line]] 1. INVENTOR INFORMATION TITLE: Inventors: a. Signature [[blank line]] Date [[blank line]] Printed Name in Full [[blank line]] Citizenship [[blank line]] Social Security Number [[blank line]] Home Address [[blank line]] City [[blank line]] State [[blank line]] Zip [[blank line]] Phone [[blank line]] Official Duties and Responsibilities [[blank lines]] [[boxed]] Percent Contribution of Inventor to the Invention [[blank line]] [[/boxed]] b. Signature [[blank line]] Date [[blank line]] Printed Name in Full [[blank line]] Citizenship [[blank line]] Social Security Number [[blank line]] Home Address [[blank line]] City [[blank line]] State [[blank line]] Zip [[blank line]] Phone [[blank line]] Official Duties and Responsibilities [[blank lines]] [[boxed]] Percent Contribution of Inventor to the Invention [[blank line]] [[/boxed]] c. Signature [[blank line]] Date [[blank line]] Printed Name in Full [[blank line]] Citizenship [[blank line]] Social Security Number [[blank line]] Home Address [[blank line]] City [[blank line]] State [[blank line]] Zip [[blank line]] Phone [[blank line]] Official Duties and Responsibilities [[blank lines]] [[boxed]] Percent Contribution of Inventor to the Invention [[blank line]] [[/boxed]] -1- [[/preprinted form]]