DOE HQ F 413 OMB Control #: 1910-NEW
(11/2014) Exp. Date: XX/XX/XXXX
Superior
Energy Performance®
Enrollment
Form
Version 2.0: 12-05-2014
The Superior Energy Performance® (SEP™) program provides a transparent, globally recognized system that facilities can use to improve their energy management and performance. SEP builds on the ISO 50001 framework for an energy management system (EnMS) and provides targets for improvements in energy performance.
Certification requires the use of the ISO 50001:2011 Energy management system-Requirements with guidance for use standard (ISO 50001)—and the American National Standard, ANSI/MSE 50021, and its normative references which specify energy performance criteria and additional requirements for the energy management system. To become certified, facilities must conform to ISO 50001 and ANSI/MSE 50021, improve energy performance, and undergo a SEP audit from an ANSI-ANAB accredited SEP Verification Body. SEP offers Silver, Gold, and Platinum certification performance levels. SEP certification is valid for three years as long as annual surveillance audits are completed. To continue SEP certification beyond three years, facilities must apply for recertification and undergo a recertification audit.
Enroll to gain access to resources for streamlining the SEP implementation process, such as program updates, tips, and phone support. No fees or commitment are required. Simply provide some basic facility and contact information to stay connected to the latest information on ISO 50001 and SEP. Enrolled facilities can also make the SEP Administrator aware of any special circumstances that relate to the facility’s SEP implementation.
How to enroll: Complete and submit the enrollment form on the following pages. Please submit the enrollment form to the SEP Administrator via email: [email protected].
For questions, contact the SEP Administrator: [email protected].
Public reporting burden for this collection of information is estimated to average 0.5 hours per response for the SEP Enrollment Form, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records & Privacy Management Division, IM-23, Paperwork Reduction Project OMB Control #: 1910-NEW, U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project OMB Control #: 1910-NEW, Washington, DC 20503.
DOE maintains the confidentiality of proprietary energy and production related data as proprietary that is submitted to the Superior Energy Performance (SEP) program by SEP certified facilities, to the fullest extent of the law. Data included within the SEP Enrollment and Application forms, SEP Energy Performance Improvement Report and SEP Voluntary Cost Benefit Form will not be released publicly. DOE will make public the following information about each SEP certified facility:
1. Facility name
2. Facility location (city, state)
3. Verified Achievement Level (e.g., Silver, Gold, or Platinum)
4. Verified Reporting Period Energy Performance Improvement
5. Certification date (month/year)
DOE will, from time-to-time, publicly share aggregate, program-wide metrics, such as number of SEP certified plants, and annual and cumulative SEP program energy savings.
All data provided to DOE is subject to the Freedom of Information Act (FOIA), however, DOE will notify partners if a FOIA request has been submitted for which their data might be responsive. DOE will consult with the partner and ensure the partner has an opportunity to inform DOE what data they view is proprietary. DOE will review the partner’s suggestions and will not release to the public any data DOE deems proprietary.
Please submit the enrollment form to the SEP Administrator via email: [email protected]. For questions, contact the SEP Administrator: [email protected].
Please enter your contact information below.
Organization Name: Click here to enter text.
Parent Company Name (if applicable): Click here to enter text.
☐Facility Enrollment
☐Enterprise-Wide Enrollment (this option is for organizations that are enrolling more than one facility for SEP). Total number of facilities enrolling in SEP: Click here to enter text.
Company Country of Origin: Click here to enter text.
Organization Contact Name: Click here to enter text.
Contact Title: Click here to enter text.
Main Contact Address: Click here to enter text.
City, State, Zip Code: Click here to enter text.
Phone Number: Click here to enter text.
Email Address: Click here to enter text.
Is your organization a DOE Better Plants Program Partner? (Please select one.)
(See http://energy.gov/eere/amo/better-plants for more information.)
☐Yes ☐No ☐Not sure
If no, are you interested in receiving information about Better Plants from DOE? (Please select one.)
☐Yes ☐No ☐N/A
(Optional) Have you used any of the following energy management resources in your energy management program implementation? (Please select all that apply.)
☐ DOE AMO Energy Resource Center (e.g., eGuide for ISO 50001, Energy Performance Indicator Tool) (http://www.energy.gov/eere/amo/software-tools)
☐ENERGY STAR energy management guidelines and tools
☐Electric or gas utility strategic energy management technical assistance or rebates
☐External energy consultant
☐ Energy equipment supplier or service provider
☐ Other: Click here to enter text.
(Optional) What factors motivate your organization’s decision to pursue SEP? (Please select all that apply.)
☐Energy cost reduction
☐Customer demand for energy and sustainability practices
☐Corporate reputation
☐Greenhouse gas emission reduction
☐External validation of energy saving
☐Other: Click here to enter text.
For Enterprise-Wide enrollment (enrolling more than one facility), please provide the following information below for each participating facility (copy and paste this page through page 5; complete for each facility).
Facility Contact Information
Facility Name: Click here to enter text.
Street Address: Click here to enter text.
Mailing Address: (if different than street address) Click here to enter text.
City, State, Zip Code: Click here to enter text.
Country: Click here to enter text.
Is facility contact same as individual in question 1e?
☐Yes ☐No
If Yes, skip to k. If No, fill in g-k.
Facility Contact Name: Click here to enter text.
Facility Contact Title: Click here to enter text.
Phone Number: Click here to enter text.
Email Address: Click here to enter text.
If you are not the Plant Manager, please include his/her contact information below; they will be included in key communications:
Plant Manager Name: Click here to enter text.
Phone Number: Click here to enter text.
Email Address: Click here to enter text.
Facility NAICS Code(s): Click here to enter text.
(http://www.census.gov/eos/www/naics/)
Does this facility have experience with ISO management systems?
☐Yes ☐No
If yes, which ISO management systems? (Please select all that apply.)
☐ISO 9001 ☐ISO 14001 ☐ISO 50001 ☐Other: Click here to enter text.
What is this facility’s estimated total annual energy bill?
Annual Total Energy Bill |
|
☐ |
< $500,000/Yr |
☐ |
$500,000 to $1,000,000/Yr |
☐ |
$1,000,001 to $2,000,000/Yr |
☐ |
$2,000,001 to $5,000,000/Yr |
☐ |
> $5,000,000/Yr |
☐ |
Not sure |
Does this facility have a dedicated energy manager1?
☐Yes ☐No
Note: Responding to the questions below is optional, however the information provided below will help the SEP Administrator gauge the implementation stage of enrollees in order to better provide useful resources. This information will not be shared or distributed.
(Optional) Name of this facility’s gas utility: Click here to enter text.
(Optional) Name of this facility’s electric utility: Click here to enter text.
(Optional) We will provide you with periodic informational emails. To add members of this facility’s energy management team on these emails, please list their names, email addresses, and roles below.
Name: Click here to enter text.
Email: Click here to enter text.
Role: Click here to enter text.
Name: Click here to enter text.
Email: Click here to enter text.
Role: Click here to enter text.
Name: Click here to enter text.
Email: Click here to enter text.
Role: Click here to enter text.
Name: Click here to enter text.
Email: Click here to enter text.
Role: Click here to enter text.
Add any additional facility enrollments below this point.
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<END OF ENROLLMENT FORM>
1 Facility staff that spends 50 percent or greater time on energy management.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Tracy Evans |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |