5900-75 Qualified Product Information Form for Roof Products

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for Roof Products

Office of Atmospheric Programs

Energy Star^® product information form for use by Energy Star qualified roof products partners

(Companies who have joined Energy Star for roof products by signing a Partnership Agreement)

You may use this form to report only those products that are sold under the company’s brand name. If your firm sells its models to another company that uses its own brand name, that company must join Energy Star and report its own products. Information from this form will be added to the list of Energy Star qualified roof products. Please copy this form and return one for each qualifying product to the address or fax number below. Note: Testing documentation is a requirement of ENERGY STAR and must accompany this QPI form.

Contact Information:

Company Name: (as listed in the PA)	Name of Person Submitting Information:
	Tel:	Fax:
	E-mail:

Roof Product Information:

Brand	Model		Initial Solar Reflectance	Solar Reflectance after 3 years	Warranty (years)
Testing Information:		Initial Solar Reflectance		Solar Reflectance After 3 Years	Roof cleaned prior to 3rd year test?
Tested By (Name of Firm or Self-Tested): Please Attach Test Data (Required)
Test Method Used:

Roof Product Description (complete the appropriate boxes below):

Type of Roof Product (Please specify in detail):	Application Markets
	Low Slope:	Steep Slope:
Types of Applications (Please describe in detail the major uses and applications this product was designed for):

Is Energy Star label clearly displayed:

____ in product literature? ____ on Internet site?

If answer to any of the above is No, please explain why: _________________________________________________________________________________________________

_________________________________________________________________________________________________

Please sign below:

Signature_________________________________________ Date__________

Printed Name______________________________________

The public reporting and recordkeeping burden for this collection of information is estimated to average 4.85 hours 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.

Please submit your completed QPI Form to ENERGY STAR for Roof Products

Email: [email protected], Fax: (202) 862-1144

1725 Eye St, NW, Suite 1000, Washington, DC 20006

Energy Star, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA

Toll-free number 1-888-STAR-YES, Web site http://www.energystar.gov

Energy Star is a registered mark.

EPA Form No. 5900-75