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**Energy Star[^®^]{.smallcaps} product information form for use by
Energy Star qualified furnace partners**

**(Companies who have joined Energy Star for furnaces by signing a
Partnership Agreement)**

*You may use this form to report only those products that are sold under
your company's brand name. If your firm sells its models to another
company that uses its own brand name, that company must join the program
and report its own products. Information from this form will be added to
the list of Energy Star qualified furnace products. Please complete this
form and send it back via **fax, e-mail, or mail to the address given
below.***

**Company Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Product
Contact Information \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (As listed in
Partnership Agreement) (For public requesting product information)**

**Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Tested by:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**(Name of Firm or Self-Tested) Tel:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Email:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Additions to Qualifying Products List:**

+-----------+------------+-------+-------+-------+-------------------+
| **Man     | **Product  | *     | **Pro | *     | **Model           |
| ufacturer | Family     | *Fuel | vides | *AFUE | Series**[^1]      |
| Name**    | Name**     | Type  | Hot   | Rat   |                   |
|           |            | (     | Water | ing** |                   |
| **(Trade  |            | e.g., | Heati |       |                   |
| Name)**   |            | Gas,  | ng?** |       |                   |
|           |            | Oil,  |       |       |                   |
|           |            | et    |       |       |                   |
|           |            | c.)** |       |       |                   |
+-----------+------------+-------+-------+-------+-------------------+
|           |            |       |       |       |                   |
+-----------+------------+-------+-------+-------+-------------------+
|           |            |       |       |       |                   |
+-----------+------------+-------+-------+-------+-------------------+
|           |            |       |       |       |                   |
+-----------+------------+-------+-------+-------+-------------------+
|           |            |       |       |       |                   |
+-----------+------------+-------+-------+-------+-------------------+
|           |            |       |       |       |                   |
+-----------+------------+-------+-------+-------+-------------------+

**Is product shipped with Energy Star label**:

\_\_\_\_\_\_\_\_ in product literature? \_\_\_\_\_\_\_\_ on Internet
site? \_\_\_\_\_\_\_\_ on product packaging?

**If answer to any of the above is No, explain why**:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Please sign below**:

Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_

Printed Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Thank you for your assistance. The Qualifying Products List is available
through the Energy Star Hotline

(1-888-STAR-YES/1-888-782-7937) and Web site
([http://www.energystar.gov](http://www.energystar.gov/)).

The public reporting and recordkeeping burden for this collection of
information is estimated to average 4.85 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.

[^1]: Please simplify model series information when possible (e.g., "All
    models beginning with\...").