5900-263 Challenge for Industry Registration Form

OMB Control Number 2060-0347

Expiration Date: XX/XX/XXXX

Approved while under OMB review

ENERGY STAR® Challenge for Industry Registration Form

Please complete this form to take the ENERGY STAR Challenge for Industry by pledging to improve the energy efficiency of your manufacturing site by 10 percent within 5 years from your baseline year. For information on requirements, supporting tools, and recognition, please visit www.energystar.gov/industrychallenge.

* Required

Site Information

Company Name *

Your answer

Site Name *

Your answer

Site Address *

Your answer

Site City *

Your answer

Site State (and/or District, Province, etc.) *

Your answer

Site ZIP Code or Postal Code *

Your answer

Site Country *

Your answer

Industry Description *

Please provide a short description of your business. Example: Our company manufactures widgets.

Your answer

Products Produced at This Site *

Your answer

Contact Information

Contact Name *

Your answer

Contact Title *

Your answer

Contact Phone *

Your answer

Contact Email *

Your answer

Baseline, Tracking, and Goals

Energy Intensity Metric *

Identify the metric used to track energy intensity. Example: Btu per pound of product.

Your answer

Explanation of Energy Intensity Metric Selection *

Please include a brief explanation of why the selected metric is appropriate. Example: "Our site produces a variety of widget types which we track by weight."

Your answer

Your answer

Baseline Year *

Please select the ending month of your 12-month baseline period. The baseline must begin in the year prior to signing up for the Challenge. The baseline can be based on the immediate past year (e.g., a site signing up in April 2014 could set their baseline as January 1, 2013 - December 31, 2013), or another consecutive 12-month period such as the most recent 12 months (e.g., a site signing up in April 2014 could set their baseline as April 1, 2013 - March 31, 2014), or the site's most recent fiscal year.

Your answer

Baseline Energy Intensity *

Please enter this site’s source energy intensity (including all electricity, fuels, steam, etc.) for the Baseline Year using the Energy Intensity Metric units identified above. For information on source energy, please refer to the ENERGY STAR Challenge for Industry Participant Handbook, Appendix 3: http://1.usa.gov/1t9EpqQ

Your answer

10% Energy Intensity Reduction Target *

Please enter this site’s source energy intensity target (i.e., energy intensity that is 10% lower than the Baseline Energy Intensity entered above).

Your answer

Formal Site File *

We have established the required formal site file. Note: a formal site file must be established at the start of participation in the ENERGY STAR Challenge for Industry, and must be verified by a Professional Engineer as a step in the recognition application process.

Yes

No

Additional Information

Is your company an ENERGY STAR Industrial Partner? *

Yes

No

Is this the first time this site has signed up for the Challenge for Industry? If no, please indicate how many times this site has signed up in the "Other" text box below. *

Yes

No

Other:

How did you learn of the ENERGY STAR Challenge for Industry? (Optional)

If you are participating as part of program promoting the Challenge please name that organization (e.g., industry association, utility) below.

Your answer

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0347). Responses to this collection of information are voluntary (Section 103(g) Clean Air Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to average 10 minutes 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 to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 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 Number 5900-263

BEFORE YOU CLICK SUBMIT: Using your browser’s Print function, please print this completed form to a PDF or paper and retain for your Formal Site File. Then click Submit.

SUBMIT

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