ENERGY STAR® Challenge for Industry Recognition Application

https://docs.google.com/spreadsheet/viewform?formkey=dG1abkRNX3VLdTBGMC1vNDNMUE5LWUE6MQ#gid=0[7/18/2012 2:32:04 PM]

OMB Control No. 2060-0347

ENERGY STAR® 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.
ENERGY STAR® Challenge for Industry Recognition Application

https://docs.google.com/spreadsheet/viewform?formkey=dG1abkRNX3VLdTBGMC1vNDNMUE5LWUE6MQ#gid=0[7/18/2012 2:32:04 PM]

OMB Control No. 2060-0347

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
ENERGY STAR® Challenge for Industry Recognition Application

https://docs.google.com/spreadsheet/viewform?formkey=dG1abkRNX3VLdTBGMC1vNDNMUE5LWUE6MQ#gid=0[7/18/2012 2:32:04 PM]

OMB Control No. 2060-0347

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 *
ENERGY STAR® Challenge for Industry Recognition Application

https://docs.google.com/spreadsheet/viewform?formkey=dG1abkRNX3VLdTBGMC1vNDNMUE5LWUE6MQ#gid=0[7/18/2012 2:32:04 PM]

OMB Control No. 2060-0347

Title * 

Email * 

Phone *

CEO Mailing Address *

Other Contact (if needed)

Contact Name

Title 

Email 

Phone

Contact Mailing Address
ENERGY STAR® Challenge for Industry Recognition Application

https://docs.google.com/spreadsheet/viewform?formkey=dG1abkRNX3VLdTBGMC1vNDNMUE5LWUE6MQ#gid=0[7/18/2012 2:32:04 PM]

OMB Control No. 2060-0347

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.
ENERGY STAR® Challenge for Industry Recognition Application

https://docs.google.com/spreadsheet/viewform?formkey=dG1abkRNX3VLdTBGMC1vNDNMUE5LWUE6MQ#gid=0[7/18/2012 2:32:04 PM]

OMB Control No. 2060-0347

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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