### ![](media/image1.jpeg){width="2.2527777777777778in" height="0.6506944444444445in"}

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### *Please submit a completed copy of this form with each model to be reviewed for Energy Star Full Qualification. Submit completed forms by mail to your ENERGY STAR Account Manger at D&R International, Ltd., 1300 Spring Street, Suite 500, Silver Spring, Maryland 20910.*

*For a copy of the Energy Star CFL Criteria-version 3.0, visit:
[**http://www.energystar.gov/index.cfm?c=cfls.pr_cfls**](http://www.energystar.gov/index.cfm?c=cfls.pr_cfls)*

<table>
<colgroup>
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<tbody>
<tr class="odd">
<td colspan="15"><strong>PART 1: To be completed by the manufacturer of
medium based screw-in bulb with integral ballast.</strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Company</strong></td>
<td colspan="3"></td>
<td></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Contact</strong></td>
<td colspan="3"></td>
<td><h4 id="section-2"></h4>
<h4 id="title">Title</h4></td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Address</strong></td>
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>City</strong></td>
<td colspan="3"></td>
<td><strong>State</strong></td>
<td colspan="5"></td>
<td colspan="3"><h1 id="section-3"></h1>
<h1 id="zip-code">Zip Code</h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Country</strong></td>
<td colspan="3"></td>
<td colspan="6"><strong>Phone Number</strong></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Fax Number</strong></td>
<td colspan="3"></td>
<td colspan="6"><strong>E-mail Address</strong></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Web Site</strong></td>
<td colspan="13"><strong><br />
</strong></td>
</tr>
<tr class="odd">
<td colspan="15"><h1
id="please-complete-the-entire-form-and-submit-a-packaging-graphic.-incomplete-forms-will-slow-the-qualification-process.-the-description-below-will-appear-at-www.energystar.gov-on-the-cfl-products-web-page.">Please
complete the entire form and submit a packaging graphic. Incomplete
forms will slow the qualification process.<br />
The description below will appear at www.energystar.gov on the CFL
Products web page. </h1></td>
</tr>
<tr class="even">
<td colspan="3"><strong><br />
Brand</strong></td>
<td colspan="2"></td>
<td colspan="5"><strong>Model Number</strong></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Wattage</strong> (watts)</td>
<td colspan="2"></td>
<td colspan="7"><h1 id="light-output-lumens"><br />
Light Output (lumens)</h1></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Bulb Life</strong> (hours)</td>
<td colspan="2"></td>
<td colspan="7"><h1 id="section-4"></h1>
<h1 id="warranty-years">Warranty (years)</h1></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Product Use</strong> <em>(check one)</em></td>
<td colspan="2"> Residential</td>
<td colspan="7"><h1 id="commercial"> Commercial </h1></td>
<td colspan="3"> Both</td>
</tr>
<tr class="even">
<td colspan="3"><h6 id="color-temperature">Color Temperature</h6></td>
<td colspan="12">___________° Kelvin <em>(Temperatures outside
2700-3000K, must be specified on packaging)</em></td>
</tr>
<tr class="odd">
<td colspan="3"><h4 id="section-5"></h4>
<h4 id="model-typedesign">Model Type/Design</h4>
<p>(<em>check or circle one</em>)</p></td>
<td colspan="5"><p> Bare- 2-D</p>
<p> Bare- mini-spiral</p>
<p> Bare- spiral</p>
<p> Bare- circline</p>
<p> Bare- twin tube</p>
<p> Bare- triple tube</p>
<p> Bare- quadruple tube</p></td>
<td colspan="7"><p> Covered- globe</p>
<p> Covered- A-line (incandescent shape)</p>
<p> Covered- reflector</p>
<p> Covered- bullet</p>
<p> Covered- candle</p>
<p> Other:</p></td>
</tr>
<tr class="even">
<td colspan="3"><h4 id="special-featuresuses">Special Features/Uses</h4>
<p><em>(check or circle all that apply)</em></p></td>
<td colspan="5"><p> Dimmable CFL</p>
<p> 3-Way Lighting</p>
<p> Bug Light</p>
<p> Table lamp use <em>(basic use)</em></p>
<p> Decorative/Vanity Use</p>
<p> Ceiling Fan Use</p></td>
<td colspan="7"><p> Hanging Pendant Use</p>
<p> Recessed Can Fixture Use</p>
<p> Indoor Fixture Use</p>
<p> Outdoor Fixture Use<br />
 Outdoor Flood Light Use</p>
<p> Other:</p></td>
</tr>
<tr class="odd">
<td colspan="3"><h4 id="where-will-this-product-be-sold-check-one">Where
will this product be sold? <em>(check one)</em></h4></td>
<td colspan="12"> U.S.  Canada  Both U.S. and Canada</td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>Package/Retail Product Number(s)</strong></p>
<p><em>Please specify additional packaging formats: i.e., product number
and packaging type, ex. 2 – blister</em></p></td>
<td colspan="9"><p>No.: _______ Package: ________</p>
<p>No.: _______ Package: ________</p></td>
<td colspan="2"><p>No.: ________ Package: _______</p>
<p>No.: ________ Package: _______</p></td>
</tr>
<tr class="odd">
<td><strong>Signature</strong></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="6"></td>
</tr>
</tbody>
</table>

Manufacturer Contact Date

<table>
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<col style="width: 2%" />
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<col style="width: 26%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><h5
id="part-2-to-be-completed-and-signed-by-a-nvlap-certified-testing-facility.-for-a-list-of-accredited-facilities-visit-the-national-institute-for-standards-and-technology-nist-site-at-httpts.nist.govtshtdocs210214214.htm.-please-attach-all-supporting-data-reports.">PART
2: To be completed and signed by a NVLAP-certified testing facility. For
a list of accredited facilities, visit the National Institute for
Standards and Technology (NIST) site at
http://ts.nist.gov/ts/htdocs/210/214/214.htm. Please attach all
supporting data reports.</h5></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="manufacturer">Manufacturer</h6></td>
<td colspan="3"></td>
<td colspan="2"><h1 id="model-number">Model Number</h1></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="2"><h6 id="report-date">Report Date</h6></td>
<td colspan="3"></td>
<td colspan="2"><h1 id="report-number">Report Number</h1></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>NVLAP-Certified Testing Facility</strong></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="3"><p><strong>Lamp efficacy</strong></p>
<p>(<em>please enter data in corresponding area)</em></p></td>
<td colspan="3"><h1 id="criteria">CRITERIA </h1>
<h1 id="must-meet-or-exceed-minimum-listed-lumens-per-watt">Must meet or
exceed minimum listed lumens per watt</h1></td>
<td colspan="4"><p><strong>AVG. BASE-UP</strong></p>
<p>Five samples <em>(required)</em></p></td>
<td><p><strong>AVG. BASE-DOWN<br />
</strong><em>(unless product is labeled in a restricted
position)</em></p>
<p>Five samples (required)</p></td>
</tr>
<tr class="even">
<td colspan="3"><h1 id="bare">Bare</h1></td>
<td colspan="3">&lt; 15 watts = <strong>45.0</strong></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><u>&gt;</u> 15 watts = <strong>60.0</strong></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Covered</strong> <em>(no reflector)</em></td>
<td colspan="3"><u>&lt;</u> 15 watts = <strong>40.0</strong></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3">15 <u>&gt;</u> lamp power &lt; 19 watts =
<strong>48.0</strong></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">19 <u>&gt;</u> lamp power &lt; 25 =
<strong>50.0</strong></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3">Lamp power <u>&gt;</u> 25 watts =
<strong>55.0</strong></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Reflector</strong></td>
<td colspan="3">Lamp power &lt; 20 = <strong>33.0</strong></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3">Lamp power <u>&gt;</u> 20 watts =
<strong>40.0</strong></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3"><h1 id="criteria-1">CRITERIA</h1></td>
<td colspan="4"><strong>AVG. BASE-UP</strong></td>
<td><strong>AVG. BASE-DOWN</strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Starting Time</strong></td>
<td colspan="3"><u>&lt;</u> 1.00 second (to the mSec)</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Color Quality</strong></td>
<td colspan="3">CRI <u>&gt;</u> 80.0</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Run-up Time</strong> (seconds)</td>
<td colspan="3"><u>&lt;</u> 3.0 minutes</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Correlated Color Temperature</strong>
(Kelvin)</td>
<td colspan="3">Between 2700K and 3000K – if not, packaging should
clearly state temperature and color of product (cool or warm)</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Power Factor</strong></td>
<td colspan="3"><u>&gt;</u> 0.50</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Operating Frequency</strong></td>
<td colspan="3"><u>&gt;</u> 40.0 kHz</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><h6 id="transient-protection">Transient
Protection</h6></td>
<td colspan="3">7 strikes</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><h6 id="hour-lumen-maintenance-lumens">100-hour Lumen
Maintenance (lumens)</h6></td>
<td colspan="3">Baseline measurement to use for calculating lumen
maintenance</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="3"><p><strong>Lumen Maintenance</strong></p>
<p><em>(10 units, 5 base-up, 5 base-down, unless product is labeled in
restricted position)</em></p></td>
<td colspan="3" rowspan="3">At 40% of rated life, must be 80% of initial
(100-hour) rating</td>
<td colspan="5">Date Test Began: __________________________</td>
</tr>
<tr class="even">
<td colspan="5"><strong>Lumens Measured:</strong>
________________________</td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Percentage:</strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2"><p><strong>Average Rated Life
Test</strong></p>
<p><em>(10 units, 5 base-up, 5 base-down, unless product is labeled in
restricted position)</em></p></td>
<td colspan="3" rowspan="2"><u>&gt;</u> 6,000 hours as declared by the
manufacturer on packaging</td>
<td colspan="5">Date Test Began: _________________________</td>
</tr>
<tr class="odd">
<td colspan="5"><strong># of Models that met Rated Life:</strong>
_____________<br />
<strong># of Models that did not meet Rated Life:</strong> ______</td>
</tr>
<tr class="even">
<td colspan="3"><strong>Signature</strong></td>
<td colspan="3"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
</tbody>
</table>

NVLAP Laboratory Technician Date