                                                     OMB Control No. 2060-0528 
                                       
                                 United States
ENVIRONMENTAL PROTECTION AGENCY   
                              Washington, DC 20460   
                          Office of Atmospheric Programs 
                    Application for Recognition of Accredited Laboratories by EPA under the ENERGY STAR[(R)] Program 
                                    Version 1.8

This form is an application for recognition of laboratories by the U.S. EPA ENERGY STAR program. To serve as an EPA-recognized, accredited laboratory for the ENERGY STAR program, please fill out and submit this form to EPA by following the instructions below. Upon confirmation of EPA recognition, you may begin to operate as an EPA-recognized, accredited laboratory for the ENERGY STAR program. 
First party laboratories that are granted EPA recognition are not required to participate in a supervised manufacturer test lab (SMTL) program as defined in Appendix A of the "Conditions and Criteria for Recognition of Certification Bodies." Certification bodies are encouraged to take EPA recognition into account when assessing a laboratory's competence. 
Instructions: 
       Read and understand the "Conditions and Criteria for Recognition of Laboratories for the ENERGY STAR Program," the full text of which is included under Section VI.
       Complete the form. All fields are required unless stated otherwise.
       Sign the form by either:
             Inserting your digital signature; or
             Printing out the form, signing it by hand, and scanning it into PDF format.
       Email the completed form with the required attachments to: Certification@energystar.gov.
Approval expires 
I. 	Laboratory Information Laboratory Name: Laboratory URL: 
      Address 1 (e.g., street address): 
      Address 2 (e.g., suite #): 
      City: 
      State: 
      Zip/Postal Code: Country: 
      Primary contact first name: 
      Primary contact last name: 
      Job title of primary contact: 
      Email: 
      Phone: 
      If mailing address of primary contact is different from the organization address, please provide it here: 
      Address 1 (e.g., street address): 
      Address 2 (e.g., suite #): 
      City: 
      State: 
      Zip/Postal Code: Country: 
      The following secondary contact information section is optional. 
      Secondary contact first name: 
      Secondary contact last (family) name: 
      Job title of secondary contact: 
      Email: 
      Phone: 
      If mailing address of secondary contact is different from the organization address, please provide it here: 
      Address 1 (e.g., street address): 
      Address 2 (e.g., suite #): 
      City: 
      State: 
      Zip/Postal Code: Country: 
 Is the Laboratory 1[st] party (i.e., manufacturer-owned)? 	 Yes / 	 No
            If yes, please provide the name of the ENERGY STAR partner/manufacturer and describe the nature of the relationship:  
            Partner/manufacturer name: 
            Nature of relationship between the 1[st] party Laboratory and partner/manufacturer: 
            
 General Requirements: Consistent with "Conditions and Criteria for Recognition of Laboratories for the ENERGY
      STAR Program," an EPA-recognized, accredited laboratory must maintain accreditation to ISO/IEC 17025, "General requirements for the competence of testing and calibration laboratories," by an EPA-recognized Accreditation Body.
 Name of EPA-recognized Accreditation Body:
 Laboratory accreditation effective date:
 Laboratory accreditation expiration date (if applicable):
 A digital copy of the Laboratory's accreditation certificate and scope of accreditation is included with this application (check box to confirm). 
            Comment (optional): 

 Scope of Accreditation: Below, please select each ENERGY STAR product category for which your lab is accredited to test products pursuant to ENERGY STAR qualification. Since EPA-recognition is per product category, EPA will recognize your Laboratory only for products the test methods of which are listed on your Scope of Accreditation. If in the future you wish to test products not checked below, please resubmit this form with the additional products checked, and your updated Scope of Accreditation. (Note: EPA will recognize laboratories for testing Windows, Doors, and Skylights through the National Fenestration Rating Council (www.nfrc.org)).
                        ENERGY STAR Product Categories 
                                  Appliances 
                                  Electronics and Office Equipment (continued) 
 Clothes Washers 
 Dishwashers  
 Refrigerators and/or Freezers 
 Telephony
 Televisions
 Uninterruptible Power Supplies
           Heating and Cooling 
Boilers 
Central Air Conditioners and Air-Source Heat Pumps 
Commercial Water Heaters
Dehumidifiers 
Furnaces 
Geothermal Heat Pumps 
Light Commercial HVAC 
Room Air Cleaners and Purifiers 
Room Air Conditioners 
Residential Water Heaters - Solar
 Enterprise Storage
 Small Network Equipment
                           Commercial Food Service 
Commercial Dishwashers
Commercial Fryers
Commercial Griddles
Commercial Hot Food Holding Cabinets  
Commercial Ice Machines  
Commercial Ovens    
Commercial Refrigerators and Freezers 
Commercial Steam Cookers 
Residential Water Heaters - Non-Solar
Climate Controls 
      Electronics and Office Equipment 
Audio/Video 
Battery Charging Systems (BCSs) 
Computers 
Displays 
Enterprise Servers 
Imaging Equipment 
Set-top Boxes & Cable Boxes 
                              Lighting and Fans 
Ceiling Fans 
Compact Fluorescent Lamps (includes GU24)  
Decorative Light Strings 
Integral LED Lamps (Decorative) 
Integral LED Lamps (Omnidirectional/Directional)  
LED package, module or array (IES LM-80-2008)  
Luminaires: Halogen (Directional) 
Luminaires: Halogen (Non-directional)  
Luminaires: High Intensity Discharge Ballasts
                                        
                                       
                  Additional product categories on next page 
Lighting and Fans (continued) 

Luminaires: High Intensity Discharge (Directional)
                                                       Home Building Materials 
 Roof Products 
Luminaires: High Intensity Discharge Lamps 
Luminaires: High Intensity Discharge (Non-Directional and subcomponents)
Luminaires: Fluorescent Ballasts
Luminaires: Fluorescent (Directional)
Luminaires: Fluorescent Lamps
                                         Other 
 Pool Pumps
Vending Machines  
Water Coolers 
Lab-grade Refrigerators/Freezers 
       
       Luminaires: Fluorescent (Non-Directional and subcomponents) 
       Luminaires: Solid State (Directional) 
       Luminaires: Solid State (Non-Directional)  Residential Ventilating Fans 
 Declaration: 
       By checking this box, I declare that I have read and agree to the terms of "Conditions and Criteria for Recognition of Laboratories for the ENERGY STAR Program," and the information submitted via this form is, to the best of my knowledge, accurate and associated with the laboratory named herein. I understand that the ENERGY STAR program will associate all information in this form with this laboratory. I understand that if any of the submitted information is found to be inaccurate, the laboratory will be removed from the list of EPA-recognized Laboratories. I understand that intentionally submitting false information to the U.S. government is a criminal violation of the False Statements Act, Title 18 U.S.C. section 1001.  
      I further declare that the Laboratory named herein will not use any ENERGY STAR mark for any purpose at any time. 
      You are required to provide your signature by either: 
 Inserting your digital signature in the box below, or,
 Printing out the form, signing the signature box below by hand, and scanning the form into PDF format.
      Chief Executive/Signatory: 
      Printed Name: 
      Job Title:      
      Date: 
 Conditions and Criteria for Recognition of Laboratories for the
      ENERGY STAR Program
In order to serve as an EPA-recognized accredited laboratory for the ENERGY STAR program, a laboratory shall agree in writing to comply at all times with the following requirements:    
General Requirements: 
 Maintain accreditation to ISO/IEC 17025, "General requirements for the competence of testing and calibration laboratories," by an EPA-recognized Accreditation Body (AB).  Noteworthy elements of ISO/IEC 17025 include requirements that laboratories shall:  
 Have a policy that sets out quality objectives, commitments and operational procedures;
 Employ experienced personnel who have the education and training needed to conduct the tests;
 Have the physical plant facilities and test equipment needed for proper testing;
 Ensure that measuring equipment is accurate and calibrated and that calibration records are maintained;
 Maintain a record of all original observations, test data and calculations; and,
 Maintain arrangements to ensure the freedom of laboratory management and personnel from any undue internal or external commercial, financial or other pressures and influences that may adversely affect the quality of their work.
      NOTE: It is EPA's expectation that laboratories will consistently maintain the impartiality of product testing. Demonstration of impartiality, consistent with the requirements of ISO/IEC 17025, shall include but may not be limited to the following:
          organization chart showing that the responsibilities, authorities, and inter-relationships of all personnel who manage, perform or verify laboratory results are free from influence that may adversely affect the quality of their work;
          dates of internal audits, audit findings, and any corrective actions taken; iii) any customer complaints and corrective action taken;
          original testing records containing sufficient information for repeatability, including the names of staff who participated;
          evidence that laboratory employees participate in and regularly pass ethics and compliance audits; and, vi) evidence that mechanisms for reporting and responding to attempts to exert undue influence on test results are in place.
 Develop and maintain separate laboratory test procedures for each accredited ENERGY STAR test method that detail how testing will be conducted utilizing the laboratory's test facilities, fixtures, equipment and personnel.
 Notify EPA/DOE immediately of any attempt to hide or exert undue influence over test results.
 Have recorded in its Scope of Accreditation its specific competence to carry out the test methods as outlined in the
   ENERGY STAR program for which the laboratory intends to test products.2
      NOTE: To decrease the burden to laboratories and accreditation bodies, EPA will not require laboratories to update their Scopes of Accreditation when an ENERGY STAR specification is revised. However, EPA will require that the laboratory ensures its methods remain consistent with the test methods described in the program requirements of the currently effective version of the specification. Further, major changes in test method, for example, when a specification revision calls for a different test method altogether from the preceding specification version, will necessitate a Scope of Accreditation update to reflect the newly required test method.   
 Allow EPA or an EPA-appointed representative, at its discretion, to witness any testing performed for qualification or verification of qualification to the requirements of the ENERGY STAR program. EPA or its appointed representative agrees to operate solely as an observer and not participate in any way with the testing activities of the laboratory.
Inter-laboratory Comparison Testing: 
 Agree to participate in relevant and available inter-laboratory comparison testing (ILC) when EPA/DOE deems it necessary.   
 Carry out ILC in accordance with normal testing/calibration and reporting procedures, unless otherwise specified in the instructions from the proficiency test provider.
 Submit to EPA/DOE upon request:
 The results of ILC;
 The analysis of those results; and,
 Detailed corrective action responses for any outlying or unacceptable results.
Reporting:  
 Submit to EPA a digital copy of the accreditation certificate and scope of accreditation. This shall include at a minimum:  
 Accreditation effective date;
 Accreditation expiration date (if applicable); and,
 ENERGY STAR-relevant accredited test methods.
 Authorize the laboratory's AB to share with EPA copies of assessment documentation related to ENERGY STAR testing, including corrective action plans and deficiency resolutions.
 Report to both EPA and the laboratory's AB within 30 days of any major changes that affect the laboratory's:
 Legal, commercial, organizational, or ownership status;
 Organization and management, e.g., key managerial staff;
 Policies or procedures, where appropriate;
 Location;
 Personnel, facilities, working environment or other resources, where significant; and,
 Other such matters that may affect the laboratory's capability, scope of recognized activities, or compliance with the ENERGY STAR requirements and relevant technical documents.
 Forward any questions related to ENERGY STAR test methods to EPA for resolution, and abide by the decisions of EPA relative to the resolution of those questions.
End of text of "Conditions and Criteria for Recognition of Laboratories for the ENERGY STAR Program" 
The public reporting and recordkeeping burden for this collection of information is estimated to average 6.7 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 
