5900-34 ENERGY STAR Participation Form - Retailer

OMB Control No. 2060-0528

®

ENERGY STAR Participation Form
for Retailers of ENERGY STAR Eligible Products:

Partner Name:
Date:

Organization Type:
(Hold Ctrl to select multiple)

Big Box Retailer
Buying Group
Distributor
Independent Retailer
Online Only Retailer

Partner will promote the following ENERGY STAR products. Please select only those check boxes relevant for
your organization. If your retail organization also owns a brand and intends to certify products as ENERGY
STAR, please fill out the Product Brand Owner Participation Form found at www.energystar.gov/join.

Product Offerings
Residential Appliances

Other Products

 Major Appliances

 Electrical Vehicle Supply Equipment

 Small Appliances

 Laboratory Grade Refrigerators and Freezers
 Pool Pumps

Commercial Food Service Equipment

 Water Coolers

 Commercial Food Service

 Vending Machines

Heating, Ventilation, and AC Products

Water Heaters

 Ceiling Fans

 Water Heaters

 Heating and Cooling
 Thermostats
 Ventilation

Home and Building Envelope Products
 Insulation Products
 Residential Storm Windows
 Windows, Doors, and Skylights

Home Electronics
 Electronics

Lighting Products
 Decorative Light Strings
 Lighting

Office Equipment
 Computers
 Datacenter Products
 Office Equipment

EPA Form No. 5900-33

ENERGY STAR Participation Form

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OMB Control No. 2060-0528

Primary Contact (if same as signatory contact, leave this blank)
Contact Name

___________________________________

Title

___________________________________

Company

___________________________________

Address

___________________________________

City

___________________________________

State

___________________________________

Zip

___________________________________

Country

___________________________________

Phone

___________________________________

Email

___________________________________

Role in Company (Hold Ctrl to select multiple)
Communications / Marketing / PR
Owner / Executive Management
Government Affairs / Corporate Relations
Legal
Technical / Engineering
Other

Additional Contact 1 (optional)
Contact Name

___________________________________

Title

___________________________________

Company

___________________________________

Address

___________________________________

City

___________________________________

State

___________________________________

Zip

___________________________________

Country

___________________________________

Phone

___________________________________

Email

___________________________________

Role in Company (Hold Ctrl to select multiple)
Communications / Marketing / PR
Owner / Executive Management
Government Affairs / Corporate Relations
Legal
Technical / Engineering
Other

Role in ENERGY STAR Program
General (receive all ENERGY STAR correspondence)
Product Specific
Alternate Primary

Return completed Participation Form to:

[email protected] or
ENERGY STAR
c/o ICF
1725 Eye Street, NW, Suite 1000
Washington, DC 20006
EPA Form No. 5900-33

ENERGY STAR Participation Form

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OMB Control No. 2060-0528

Additional Contact 2 (optional)
Contact Name

___________________________________

Title

___________________________________

Company

___________________________________

Address

___________________________________

City

___________________________________

State

___________________________________

Zip

___________________________________

Country

___________________________________

Phone

___________________________________

Email

___________________________________

Role in Company (Hold Ctrl to select multiple)
Communications / Marketing / PR
Owner / Executive Management
Government Affairs / Corporate Relations
Legal
Technical / Engineering
Other

Role in ENERGY STAR Program
General (receive all ENERGY STAR correspondence)
Product Specific
Alternate Primary

Additional Contact 3 (optional)
Contact Name

___________________________________

Title

___________________________________

Company

___________________________________

Address

___________________________________

City

___________________________________

State

___________________________________

Zip

___________________________________

Country

___________________________________

Phone

___________________________________

Email

___________________________________

Role in Company (Hold Ctrl to select multiple)
Communications / Marketing / PR
Owner / Executive Management
Government Affairs / Corporate Relations
Legal
Technical / Engineering
Other

Role in ENERGY STAR Program
General (receive all ENERGY STAR correspondence)
Product Specific
Alternate Primary

Return completed Participation Form to:

[email protected] or
ENERGY STAR
c/o ICF
1725 Eye Street, NW, Suite 1000
Washington, DC 20006

ENERGY STAR Participation Form
The public reporting and recordkeeping burden for this collection of information is estimated to average 7.4 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.
EPA Form No. 5900-33

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