Form 5900-34 Retailers Participation Form

OMB Control No. 2060-05280
Expiration Date: 1/31/2022

®

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

 Smart Home Energy Management Systems

 Commercial Food Service

 Water Coolers
 Vending Machines

Heating, Ventilation, and AC Products
 Ceiling Fans
 Heating and Cooling

Water Heaters
 Water Heaters

 Thermostats
 Ventilation

Office Equipment
 Computers

Home and Building Envelope Products
 Insulation Products

 Datacenter Products
 Office Equipment

 Residential Storm Windows
 Windows, Doors, and Skylights

Lighting Products
 Decorative Light Strings

Home Electronics

 Lighting

 Electronics

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No.
2060-0528). Responses to this collection of information are voluntary (Section103(g) of the 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 be 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 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 No. 5900-34

ENERGY STAR Participation Form

1

OMB Control No. 2060-0528
Expiration Date: 1/31/2022

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

2

OMB Control No. 2060-0528
Approval Continues Pending OMB Review

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

EPA Form No. 5900-34

3