ENERGY STAR® Challenge for Industry RecognitionApplication

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 ofthe 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**  **wi th**  **all statements**  **made above.**  ***** Yes **To gain**  **recognition in**  **the ENERGY**  **STA R**  **Challenge for**  **Industry, the**  **site’s company**  **must be**  **an ENERGY**  **STA R**  **partner. Is**  **your company**  **an ENERGY**  **STA R**  **partne r** **?** ***** 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 RecognitionApplication

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 Ad** **dress**ENERGY STAR® Challenge for Industry RecognitionApplication

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 ifthe 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**  **Ad dress**  *****



## Chief **Executive Officer**  **CEO Name**  *****ENERGY STAR® Challenge for Industry RecognitionApplication

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**  **Ad dress** ENERGY STAR® Challenge for Industry RecognitionApplication

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**  **applicatio n** **?** ***** Site Contact Corporate Energy Director Chief Executive Officer Other Contact **Who should**  **receive the**  **certificate of**  **recognition that**  **EPA wi** **ll mail**  **upon completion**  **of review**  **of this**  **applicatio n** **?** ***** EPA will mail a congratulatory letterto 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 wo** **uld like**  **EPA to**  **consider.**ENERGY STAR® Challenge for Industry RecognitionApplication

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