ENERGY STAR® Challenge for Industry Registration Form

https://docs.google.com/spreadsheet/viewform?pli=1&formkey=dGV3dmVrZ0hKcXZRMkRYZkZZN2lvRGc6MQ#gid=0[7/16/2012 12:53:23 PM] OMB Control No. 2060-0347 

# ENERGY **STAR® 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.ENERGY STAR® Challenge for Industry Registration Form

https://docs.google.com/spreadsheet/viewform?pli=1&formkey=dGV3dmVrZ0hKcXZRMkRYZkZZN2lvRGc6MQ#gid=0[7/16/2012 12:53:23 PM] OMB Control No. 2060-0347

**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**  *****ENERGY STAR® Challenge for Industry Registration Form

https://docs.google.com/spreadsheet/viewform?pli=1&formkey=dGV3dmVrZ0hKcXZRMkRYZkZZN2lvRGc6MQ#gid=0[7/16/2012 12:53:23 PM] OMB Control No. 2060-0347 **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 1 2-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 1 2-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)** ENERGY STAR® Challenge for Industry Registration Form

https://docs.google.com/spreadsheet/viewform?pli=1&formkey=dGV3dmVrZ0hKcXZRMkRYZkZZN2lvRGc6MQ#gid=0[7/16/2012 12:53:23 PM] OMB Control No. 2060-0347 (E.g., Total Source Energy in BTUs) **10% Reduction**  **Target** ***** (E.g. Your target annual energy intensity) **Tracking Sy** **stem** ***** 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. 

## Ad**ditional Information**  **Is your**  **company an**  **ENERGY STA** **R Industrial**  **Partne r** **?** ***** Yes No **Is this**  **the first**  **time this**  **site has**  **signed up**  **for the**  **Challenge for**  **Industr y** **? 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 STA** **R Challenge**  **for Industr** **y ?**  **(Optional)** If you are paricipating as part of a promoter organization's initiative (e.g., industry association, utility), please name that organization below.ENERGY STAR® Challenge for Industry Registration Form

https://docs.google.com/spreadsheet/viewform?pli=1&formkey=dGV3dmVrZ0hKcXZRMkRYZkZZN2lvRGc6MQ#gid=0[7/16/2012 12:53:23 PM] OMB Control No. 2060-0347 Powered by Google Docs Report Abuse - Terms of Service - Additional Terms 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