ENERGY STAR® Challenge for Industry Registration Form

OMB Control Number 2060-0347

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.

Site Information

Company Name

This is a required question

Site Name

This is a required question

Site Address

This is a required question

Site City

This is a required question

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

This is a required question

Site ZIP Code or Postal Code

This is a required question

Site Country

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Industry Description

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

This is a required question

Products Produced at This Site

This is a required question

Contact Information

Contact Name

This is a required question

Contact Title

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Contact Phone

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Contact Email

This is a required question

Baseline, Tracking, and Goals

Energy Intensity Metric

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

This is a required question

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."

This is a required question

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.

This is a required question

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

This is a required question

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).

This is a required question

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.

This is a required question

Additional Information

Is your company an ENERGY STAR Industrial Partner?

This is a required question

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:

This is a required question

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

If you are paricipating as part of a promoter organization's initiative (e.g., industry association, utility), please name that organization below.

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The public reporting 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, 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 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.