EPA's WasteWise Program (State)

Partner Registration Form

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

Section I: Facility Information
Organization Name: _____________________________________________________________________________________________________
Principle Contact:________________________________________________________________________________________________________
Address:_________________________________________________________________________________________________________________
City:_ _________________________________________________ State:___________________________ Zip: _____________________________
Phone Number:________________________________________ Fax:_ ___________________________ Email: ___________________________
Industry Sector, or Type of Government:___________________________________________________________________________________
Check if a: o Subsidiary or o Division.  Name of Parent Company (if applicable: ____________________________________________
Facilities to be Included in
Approximate Number of
Initial Waste Reduction Efforts: _______________________________________________________ Employees at These Facilities:_________

Section II: How You Heard About WasteWise
o Referral from Another Company, Government, or Institution (Name): _____________________________________________________
o Periodical/Publication (Name):_ __________________________ o Workshop/Conference (Sponsor): ____________________________
o WasteWise Web Site
o Direct Mail from WasteWise
o Other EPA Program
o PSA/Advertisement
o Trade Association
o Other (Specify): ____________________________________________
Section III: Waste Reduction Priorities
Please indicate which waste reduction activities are of most interest to your organization.

Waste Prevention Activities
Office Supplies/Paper

Food/Yard Waste

o Use reusable supplies
o Duplex copy/print
o Distribute materials electronically
o Other____________________________________________

o Implement a donation program
o Use leftover food for animal feed
o Compost
o Other____________________________________________

Packaging Materials

Electronics

o Eliminate packaging
o Purchase items in bulk
o Work with vendors to decrease packaging
o Other____________________________________________

o Refurbish/upgrade existing equipment
o Donate reusable equipment
o Participate in a computer leasing program
o Other____________________________________________

Recycling Activities

Buy-Recycled/Manufacture-Recycled Activities

o Collect a new material for recycling:

o Purchase a new product made from recycled content:

(Material:_ __________________________________________ )

(Product:____________________________________________ )

o Collect more of the same material:

o Increase recycled content of a product already purchased:

(Material:_ __________________________________________ )

(Product:____________________________________________ )

o Reduce contamination of recyclables
o Improve signage/employee education about recycling

o Increase spending on recycled content products
o Increase recycled-content of product you manufacture:

o Other____________________________________________

o Other____________________________________________

(Product:____________________________________________ )

Registration Submission Approval
Name of Senior Official (print): _________________________________________ Signature:_ _______________________________________
Title: _ ______________________________________________________________________________ Date:_ ______________________________

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

OMB Control 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.