



  ENERGY STAR(R) Challenge for Industry Recognition


  Application




  As the energy manager for my company and/or site, I am writing to nominate the following site for recognition for achieving the ENERGY STAR Challenge for Industry.

  I affirm that this site meets the conditions necessary to qualify for the ENERGY STAR Challenge for Industry recognition by achieving a10% reduction in energy intensity within 5 years of establishing a baseline.

  I have personally examined and am familiar with the information contained in the Statement of Energy Improvement.  The information is based on reasonable inquiry and is, to the best of my knowledge, true, accurate, and complete.  I have no reason to believe the site would not meet all EPA program requirements for receiving the ENERGY STAR Challenge for Industry recognition.

  I understand the U.S. Environmental Protection Agency reserves the right to request and review any records which support the data used to calculate the energy intensity reduction for this site.
  I also certify that I am maintaining a file on this site in accordance with the ENERGY STAR Challenge for Industry data management requirements.  Furthermore, I agree to associate the achievement of the ENERGY STAR Challenge for Industry only with the aforementioned site and to adhere to the ENERGY STAR Identity Guidelines.

  IMPORTANT: Upon completing this online application form, you must submit the site's original, signed Statement of Energy Improvement by delivery or courier service (do not send via US Postal Service) to Rebecca Hindin, ENERGY STAR, U.S. Environmental Protection Agency,
  1310 L Street, NW (Room 913L), Washington, DC  20005 to complete the application process.
  * Required

  I agree with all statements made above. *

                                        Yes



  To gain recognition in the ENERGY STAR Challenge for Industry, the site's company must be an ENERGY STAR partner. Is your company an ENERGY STAR partner? *
                                        Yes

                                        No






  Site Information



  Company Name *
  Enter the company name exactly as it should appear in recognition materials.


  Site Name *
  Enter the site name exactly as it should appear in recognition materials.







               Site Mailing Address *
               Enter the site's full mailing address (including street address, city, district/state/province, and zip code/postal code) exactly as it should appear in recognition materials.













               Site Country *





               Percent Energy Intensity Reduction Achieved *





               Final Energy Intensity *








               Site Contact



               Site Contact Name *
               Please enter the site contact's full name.





               Title * Email * Phone *
               Site Contact Mailing Address


               Complete this question only if the site contact's mailing address is different from the site mailing address.
















               Corporate Energy Director



               Corporate Energy Director Name *





               Title * Email * Phone *
               Corporate Energy Director Mailing Address *
















               Chief Executive Officer



               CEO Name *



               Title * Email * Phone *
               CEO Mailing Address *
















               Other Contact (if needed)



               Contact Name





               Title Email Phone
               Contact Mailing Address


















               Questions and Mailings



               Please indicate the submitter of this online application form. *

                  Site Contact

                  Corporate Energy Director Chief Executive Officer Other Contact



               Who should we contact with questions regarding this application? *

                  Site Contact

                  Corporate Energy Director Chief Executive Officer Other Contact



               Who should receive the certificate of recognition that EPA will mail upon completion of review of this application? *
               EPA will mail a congratulatory letter to all contacts listed (who are located in the US). One certificate will be prepared and mailed to the individual selected below. The individual selected must have a US -based address.
                  Site Contact

                  Corporate Energy Director Chief Executive Officer Other Contact



               Please enter any additional comments or requests that you would like EPA to consider.






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               The public reporting burden for this collection of information is estimated to average 20 minutes 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.

EPA Form 5900-262

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