5900-21 Small Business Network Form

OMB No. 2060-0347

Join the Small Business ENERGY STAR Network

Yes, I would like to join the Network of small businesses working with ENERGY STAR.

I believe that greater energy efficiency can increase the financial health of my organization and aid in preserving the environment for future generations. On behalf of my organization, I pledge to buy ENERGY STAR equipment and upgrade the energy efficiency of my facilities whenever financially viable. As part of the Network, I may use the ENERGY STAR promotional mark in accordance with the ENERGY STAR identity guidelines.

* indicates a required field.

Type of Organization *

Small Business

Non-Profit

Contact Information *

Name: *

Title: *

Organization Name: *

Address 1: *

Address 2:

City: *

State:

Zip: *

Phone: *

Fax:

Web Address:

E-Mail: *

Your e-mail address is used only to send your “Welcome to ENERGY STAR” package and your quarterly “ENERGY STAR E-Update” (4 issues annually). Your e-mail address will not be “spammed” or sold by ENERGY STAR.

Approximate facility sq. footage: *

Number of units (if applicable):

Do you Rent or Own? *

Rent

Own

Number of employees/members:

How did you hear about ENERGY STAR?

Name of Referring Association:

The public reporting burden for this collection of information is estimated to average 1 minute 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.

EPA Form 5900-21