National Idea Indigenous and Knowledge Exchange (NIKE)

 

Application Form for Submitting Indigenous Knowledge to NIKE

 

 

Submit your Indigenous Knowledge online at: www.geocities.com/nf_net/nike.html

 

 

Instructions for the applicant:

1.      Please use extra paper wherever necessary

2.      Please fill in all the columns

3.      Submit this form in triplicate and keep a copy with yourself for record

4.      In case of any difficulty please phone us at +91-1662-321010

5.      Send all entries by registered post only in a sealed envelope to NIKE, 10-C Friends Colony, Hisar-125 001, India

6.      Applicants from India should send three self addressed envelopes of size 10x23 cm each affixed with postal stamps of Rs 10

7.      Please send 5 coloured/B&W photographs of Indigenous Knowledge provider(s)

8.      Please send attested photostat copies of proof of residence  and nationality (like Driving License, Passport, Ration card, Voter Identity Card, Identity Card)

9.      All documents submitted should be attested and signed by the respective applicant(s)

10.  Please send a money order of Rs 300 only (for applicants from India)/ US $ 60 only (for applicants from countries other than India) in favor of Editor BJS) to NIKE, 10-C Friends Colony, Hisar-125 001, India only towards membership fee which will entitle the Indigenous Knowledge provider to receive regular information / NIKE newsletter free of cost

 

 

 

1. Entry Idea #                           000000001/            Feb/2004                (for office use only)

2.

Date of Documentation: 22 February, 2004 _________________________

3.

Date of receipt:_________________(for office use only)

4. Secrecy Category: Highly Sensitive/Sensitive/Normal/Defence Application (for office use only)

5. Technical Category: Mechanical/ Electronic/Chemical/Biochemical/Biological/Agricultural/ Defence/Social/Health (for office use only)   

6. Place: Hisar

7. Mode of submission: Post/Courier/By Hand/Any other_______________________________

8. Title of the Indigenous Knowledge:________________________________________________ Idea Related to Automatic Putting Off Of Gas supply to LPG gas stove in case the fire goes off due wind or any other reason etc.____________________________________________________________________________________________________________________________________________________________

 

9. Name(s) of the IdeaIndigenous Knowledge Provider(s): Dr Sudhir Kumar Kaura___________________________________

10. Nationality:_________________                   

           

Profession:_________________                    Hobbies:__________________________________           

Educational Qualification:_________________________________________________________

Postal Address of the IdeaIndigenous Knowledge Provider: __________________________________

 

Permanent Home Address of IdeaIndigenous Knowledge Provider: ____________________________

 

 

Telephone of the IdeaIndigenous Knowledge Provider:______________________________________

 

E-mail of the IdeaIndigenous Knowledge Provider:_________________________________________

 

Internet address of the Indigenous Knowledge Provider:_________________________________

Fax of the IdeaIndigenous Knowledge Provider:___________________________________________

 

Name of the first Nominee: ___________________________       Share: 100%

Name of the second Nominee: ___________________________ Share:___%

Postal Address of the Nominee: ___________________________

First Nominee:

Permanent Home Address of Nominee: ______________________________________________

Telephone of the Nominee:________________________________________________________

E-mail of the Nominee:___________________________________________________________

Internet address of the Nominee:____________________________________________________

Fax of the Nominee:______________________________________________________________

First Nominee:

Permanent Home Address of Nominee: ______________________________________________

Telephone of the Nominee:________________________________________________________

E-mail of the Nominee:___________________________________________________________

Internet address of the Nominee:____________________________________________________

Fax of the Nominee:______________________________________________________________

 

How the ideaIndigenous Knowledge of this knowledge came to IdeaIndigenous Knowledge Provider (List the observations, discussions, references, or any other source like person, book, film, etc. which helped in Indigenous Knowledge generation, etc.):______________________________________

 

Perspective of the Problem:________________________________________________________

 

What possible products can be made from the knowledge generated by you?:_________________

Can you provide further technical inputs, which will help in better commercial use of the Indigenous Knowledge? Yes/No

Target prospective beneficiaries of your Indigenous Knowledge?:__________________________

How your ideaIndigenous Knowledge will benefit the consumers beneficiary? :____________________________

 

Possible technical problems anticipated by you?:_______________________________________

 

Possible problems related to consumer acceptance?:_____________________________________

 

Have you developed or plan to develop any model, drawing, prototype based on your Indigenous Knowledge? Yes/No

If yes then please submit details of model, drawing, and prototype based on your Indigenous Knowledge (including photographs, video, diagrams, problems, and resources needed for this purpose:_______________________________________________________________________

Should your the ideaIndigenous Knowledge be shared freely? Yes / No

 

Should the your ideaIndigenous Knowledge be sold to prospective clients as a technological input with one time fee only? Yes/No

If yes, what should be the minimum fee of the deal acceptable to you?______________________

 

Should your Indigenous Knowledge be sold to prospective clients including the other inputs submitted by you like drawings, prototype, as a technological input with one time fee only? Yes/No/Not Applicable

If yes, what should be the minimum fee of the deal acceptable to you?______________________

Should your Indigenous Knowledge be shared/sold only to government due to its sensitive nature? Yes/No/Not Applicable

If yes, what should be the minimum fee of the deal acceptable to you?______________________

Should the ideaIndigenous Knowledge be given on condition of anonymity of ideaIndigenous Knowledge provider? Yes/No

 

Should the ideaIndigenous Knowledge be given to prospective client on benefit sharing basis on long termlong-term basis like royalty? Yes/No

If yes, what should be the minimum rate of royalty fee acceptable to you?___________________

 

Do you agree with providing a portion of the economic gains towards the Management of NIKE for following purpose? 

120 per cent for meeting its operational expenditure

37 per cent towards creating a fund to generously help ideaIndigenous Knowledge providers in developing prototypes and products based on their ideaIndigenous Knowledges

 

73 per cent towards providing insurance and other benefits to all ideaIndigenous Knowledge providers

5 per cent towards creating an Emergency Fund for providing help to the needy Indigenous Knowledge providers and employees of NIKE and sister organization in case of emergency situation

 

Yes / No

Please list any other way in which you would like to contribute to sustain activities of NIKE__________________________________________________________________________

Any other information which you wish to submit:

Declaration by the Applicant:

I, the undersigned hereby solemnly affirm that:

the information provided above is true to the best of my knowledge and belief,

the Indigenous Knowledge reported above is my own and it has not been copied from any other individual or organization and is not part of patented information and I will be solely responsible for any dispute arising of infringement of any law related to patent or proprietary information, etc. arising out of my Indigenous Knowledge,

I am sharing this Indigenous Knowledge with NIKE in good faith and it has not been shared or discussed with any other individual or organization with commercial interests,

I understand that NIKE is supposed to maintain the confidentiality of the Indigenous Knowledge but NIKE will not be responsible for the misuse of my Indigenous Knowledge by the persons with whom I have discussed this Indigenous Knowledge,

NIKE will not be responsible for any dishonor of the agreement by third party which will be  engaged as the commercial translator of the Indigenous Knowledge with due agreement of the Indigenous Knowledge provider,

in case of any counter claim or dispute, I will be responsible for pursuing any legal or other dispute and will bear all the expenditure incurred thereon.

 

 

 

Date:                                                                Signature of the Indigenous Knowledge Provider

Place:                                                               Name of the Indigenous Knowledge Provider

Name, Address, Telephone, Fax and Email of the First Witness:

 

Name, Address, Telephone, Fax and Email of the Second Witness:

 

Declaration by the Applicant:

I the undersigned hereby solemnly affirm that:

the information provided by the Indigenous Knowledge provider will be kept confidential,

agreement related to commercial translation of the Indigenous Knowledge will be done in accordance with the options and information given by the Indigenous Knowledge provider in the above preforma,

NIKE or any of its employee will not charge any fee from the Indigenous Knowledge provider for processing the Indigenous Knowledge except for membership fee which will entitle the Indigenous Knowledge provider to receive regular information and NIKE newsletter free of cost,

NIKE will not be responsible for the dishonor of the agreement between the Indigenous Knowledge provider and the Indigenous Knowledge translator,

NIKE will not bear the fee incurred on filing patent or value addition on behalf of the Indigenous Knowledge provider if needed before commercial translation of the Indigenous Knowledge.

 

 

Date:_________                                              Signature of the Authorized Representative of NIKE

Place: :_________                                         Name and Designation of the Authorized Signatory

 

 

Signature, Name, Address, Telephone, Fax and Email of first Witness who knows about the Indigenous Knowledge provider and/or his/her Indigenous Knowledge:

 

 

Signature, Name, Address, Telephone, Fax and Email of second Witness who knows about the Indigenous Knowledge provider and/or his/her Indigenous Knowledge: