Modular Certifier Application

I, (Name of Certifier) 	 hereby assert that I meet or exceed all
required capabilities and qualifications to provide plant certification
services under the ENERGY STAR Modular Home Program as indicated by
completing the information on this form. In addition, I hereby state
that I do not have financial interests in any factory home producer or
builder, nor do I provide services that might affect my capacity to
evaluate compliance with the ENERGY STAR program and render reports of
findings objectively and without bias. Other persons performing services
related to ENERGY STAR under my authority also meet these requirements.

Signature of Authorized 

Company Representative: 		Date: 	

Company: 	

Address: 	

City: 		State: 		Zip: 	

Phone: 		Fax: 	

E-Mail: 				

Modular housing design, construction and installation methods

(Must check all boxes below)

(	Working knowledge of the residential building codes

Working knowledge of the plant production processes

Working knowledge of modular home design approval and inspection process

(	Knowledge of modular home design, construction, installation, material
use and fabrication

Building science and energy efficiency experience

(Must check at least one box below)

(	Certified Home Energy Rating System (HERS) rater or provider

(	Licensed Engineer or Architect

(Must check all boxes below)

(	Hands-on experience conducting duct and whole-house air leakage
measurements

(	Experience and training in the principles of building science

(	Experience and training in energy efficiency construction practices

Document preparation and record keeping

(Must check)

(	Capability to maintain computer records and communicate via E-mail

Submit this form to SBRA:

Fax number: 212-496-5389, or 

Mailing address: 2109 Broadway, Suite 200, New York, NY 10023, or

E-Mail: info@research-alliance.org

If approved, SBRA will return a countersigned copy of this application
to the Certifier. The Certifier shall provide a copy of the approved
application to the plant. 

Do not write in this space.

SBRA Approval:	 Date: 	

OMB Control No. xxxx-xxxx

Energy Star Modular Homes	Rev.   DATE \@ "M/d/yyyy"  9/17/2009 

EPA Form 5900-193

The government estimates the average time needed to fill out this form
is 0.17 hours and welcomes suggestions for reducing this effort. Send
comments (referencing OMB Control Number) to the Director, Collection
Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460.

