



  ENERGY STAR(R) Challenge for Industry Registration


  Form




  Please complete this form to take the ENERGY STAR Challenge for Industry by pledging to improve the energy efficiency of your manufacturing site by 10 percent within 5 years from your baseline year. For information on requirements, supporting tools, and recognition, please visit www.energystar.gov/industrychallenge.
  * Required




  Site Information



  Company Name *





  Site Name * Site Address * Site City *
  Site State (and/or District, Province, etc.) *





  Site Zip Code or Postal Code *





  Site Country *





  Industry Description *
  Please provide a short description of your business. Example: Our company manufactures widgets.



















               Products Produced at This Site *













               Number of Employees at This Site (Optional)








               Contact Information



               Contact Name * Contact Title * Contact Address * Contact City *
               Contact State (and/or District, Province, etc.) *





               Contact Zip Code or Postal Code *






               Contact Country * Contact Phone * Contact Email *



               Baseline, Tracking, and Goals



               Energy Intensity Metric *





               Explanation of Energy Intensity Metric Selection *
               Please include a brief explanation of why the selected metric is appropriate. Example: Our site produces a variety of widget types which we track by weight.













               Baseline Year *
               Please select the ending month of your 12-month baseline period. The baseline must begin in the year prior to signing up for the Challenge. The baseline can be based on the immediate past year (e.g., a site signing up in April 2012 could set their baseline as January 1, 2011 - December 31,
               2011), or another consecutive 12-month period such as the most recent 12 months (e.g., a site signing up in April 2012 could set their baseline as April 1, 2011 - March 31, 2012), or the site's most recent fiscal year.
                                         December 2011



               Baseline Energy Intensity *





               Baseline Total Energy (Optional)


               (E.g., Total Source Energy in BTUs)





               10% Reduction Target *
               (E.g. Your target annual energy intensity)





               Tracking System *
               Please check the primary tracking system(s) you plan to use.

                  Internal System

                  Portfolio Manager

                  ENERGY STAR Energy Tracking Tool (ETT)

                  ENERGY STAR Plant Energy Performance Indicator (EPI)



               Energy Tracking Plan *
               Please check the appropriate response(s).

                  We have existing policies and procedures for managing energy data. We have established a Challenge for Industry Energy Tracking Plan.






               Additional Information



               Is your company an ENERGY STAR Industrial Partner? *

                  Yes

                  No



               Is this the first time this site has signed up for the Challenge for Industry? If no, please indicate how many times this site has signed up in the "Other" text box below. *
                  Yes

                  No

                  Other:




               How did you learn of the ENERGY STAR Challenge for Industry? (Optional)
               If you are paricipating as part of a promoter organization's initiative (e.g., industry association, utility), please name that organization below.


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The public reporting burden for this collection of information is estimated to average 10 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 5900-263


