6100-17 Awards Application Form - Retail/Distributor

Retailer and Distributor - Awards Application

Page 1 of 2

Section 1: General Information
Please fill out and submit this form electronically to WaterSense by Monday, April 1, 2013. If you have any questions,
please refer to the Frequently Asked Questions page or email the WaterSense Helpline.
To save a draft of this application, select “Save my progress and resume later”. You will be prompted to provide an email
address and password that you will use to re-enter the form. WaterSense does not have access to these passwords,
so please keep your password in a safe place.
Please fill in the following information as it relates to your organization:

Organization Name Please select...

Number of Stores or Showrooms (if Applicable)
Please enter a number without commas.
Number of Customers, Annually (Approximately) *
Please enter a number without commas.
Number of Employees in the U.S. (Approximately) *
Please enter a number without commas.
If your company has brick and mortar stores, please provide the percentage of stores that offered
WaterSense labeled products in 2012:
By what percentage did your total WaterSense labeled stock assortment (online and in stores) increase
from 2011 to 2012?
Contact Name (for awards-related communications) *
Title
Phone *
Fax
Email *

Format (xxx xxx xxxx)

Section 2: Eligibility
Please verify your eligibility: * 
 Yes, our organization became a WaterSense partner prior to January 1,



 Yes, our organization submitted a 2012 annual reporting form.



2013. 

Section 3: Organization Description
Briefly describe your organization in no more than 300 words. If selected to receive an award, this
description may be used in recognition materials. *



Section 4: Written Statement
If you haven’t done so already, please download, complete, and save your written statement.

Please upload your final written statement, in which you have addressed the evaluation criteria. *
Browse...

Acceptable file formats: Word or PDF.

Page 2 of 2

Section 5: Supporting Materials
Please note: WaterSense is no longer accepting hard copy supporting materials. Partners are also asked to limit their
electronic supporting materials to 25 pages. Additional supporting materials will not be reviewed.

Please upload any supporting materials that help demonstrate the accomplishments described in your
written statement. Including supporting materials is not required, but is strongly encouraged. To upload
additional supporting materials, please use the "Upload more supporting materials" link below the first
record.
Browse...

Upload more supporting materials
Please note: Individual files may not exceed 5 MB. Total file size may not exceed 20 MB.
We understand that some high-resolution photos may be quite large and push your application over the 20 MB file size
limit. Therefore, you may send up to 10 additional photos of your 2012 WaterSense-related activities to
[email protected]. These photos may be used in recognition materials if your organization is selected for an
award. Materials other than photos sent to this email address will not be reviewed with your application.
Your application form, including the written statement and supporting materials, must be submitted by Monday, April 1,
2013 to be considered for an award.
On the following page, you will be asked to review your responses. You must select "confirm" at the bottom of the
following page to submit your award application to WaterSense.
Please note, you may need to try different printer settings or print as a PDF to print the full report for your records. We
apologize for any inconvenience.
Need assistance with this form?

OMB Control Number 2040-0272
Approval Expires 06/30/2013
EPA Form Number 6100-17. The public reporting and record keeping burden for this collection of
information is estimated to average 25 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 Avenue, NW,
Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed
form to this address.