EPA's WasteWise Program (Private Sector)

Endorser
Registration Form

OMB No. 2050-0139
Expiration Date: July 31, 2007

My organization is
ready to become a
WasteWise Endorser!

Section I: Organization Information
Organization Name: _____________________________________________________________________________________________________
Principal Contact: ___________________________________________________ Title:________________________________________________
Address:_________________________________________________________________________________________________________________
City:_ _____________________________________________________________ State:_ ______________ Zip: _____________________________
Phone Number:_________________________________________________________________________ Fax: _____________________________
Email:___________________________________________________________________________________________________________________
Approximate number of business members in your organization:_ ___________________________________________________________
(If you like, please attach a list of your members or information about your organization.)

What are the primary business sectors represented by your organization? (Please indicate the SIC Codes if possible.)
Sector:___________________   SIC Code:_ ____________________   Sector:_ ______________________   SIC Code:_______________________
Sector:___________________   SIC Code:_ ____________________   Sector:_ ______________________   SIC Code:_______________________

Section II: Commitments
As a WasteWise Endorser, my organization commits to conduct activities in each of the following two areas:
1) Within the next six months, initiate a campaign to recruit my organization’s member companies to become WasteWise
partners. (Please briefly describe your planned activities.)

2) After completing the membership drive, provide my organization’s members with ongoing promotion of the WasteWise
program and/or information on waste reduction strategies. (If known, please briefly describe your planned activities. If not
yet known, you may notify WasteWise of your plans at a later date.)

Name of Senior Official (print): _____________________________________________ Signature:____________________________________
Title: _ ____________________________________________________________________ Date:_________________________________________

Please fax to WasteWise c/o ICF International at (703)934-3183 or
email to:

OMB No. 2050-0139
Approval expires July 31, 2007
The public reporting and recordkeeping burden for this collection of information is estimated to average 1 hour 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.