5900-33 ENERGY STAR Participation Form - Product Brand Owne

OMB Control No. 2060-0528

®

ENERGY STAR Participation Form
for Product Brand Owner of ENERGY STAR Eligible Products:

Partner Name:
Date:
List of brand(s) that will be submitted for ENERGY STAR certification:
__________________________________________________________________________________________________
Product Brand Owner (Manufacturer)
Organization Type:
Product Brand Owner (Labeler)
(Hold Ctrl to select multiple) Product Brand Licensee

Markets where ENERGY STAR
products will be shipped:

United States
Canada

Brand Owner (Labeler): Organization that labels products manufactured by another company with its own brand(s).
Brand Owner (Manufacturer): Organization that manufactures products and labels them with its own brand(s).
Brand Licensee: Organization that manufactures products and labels them with a brand they have licensed from a brand owner organization.

Note: Partnership is only available for product brand owners who sell products eligible for ENERGY STAR certification in
the U.S./Canada under the brand(s) listed. Consistent with the Partnership Commitments referenced in the terms of the
Partnership Agreement:
1. The Partner is required to adhere to third-party certification requirements, including verification testing; and
2. The Partner is required to submit annual unit shipment data by March 1st for the previous Calendar Year.
Partner will certify the following ENERGY STAR products. Please select only those check boxes relevant for your
organization. Please fill out a separate Participation Form if you would like to participate in other program
areas (e.g., ENERGY STAR retailer) at www.energystar.gov/join.
Residential Appliances
 Clothes Dryers
 Clothes W ashers
 Dishwashers
 Refrigerators and/or Freezers
 Residential Dehumidifiers
 Room Air Cleaners
 Room Air Conditioners
Commercial Food Service Equipment
 Commercial Coffee Brewers
 Commercial Dishwashers
 Commercial Griddles
 Commercial Fryers
 Commercial Hot Food Holding Cabinets
 Commercial Ice Machines
 Commercial Ovens
 Commercial Refrigerators and Freezers
 Commercial Steamers
Home Electronics
 Audio/Video Equipment
 Set-top Boxes
 Small Network Equipment
 Telephony
 Televisions
Heating, Ventilation, and AC Products
 Boilers
 Central ACs and Air-source Heat Pumps
 Commercial Boilers
 Connected Thermostats
 Furnaces
 Geothermal Heat Pumps
 Light Commercial HVAC
 Residential Ceiling Fans
 Residential Ventilating Fans
EPA Form No. 5900-33

Home and Building Envelope Products
 Residential Insulation Products
 Residential Storm Windows (available for certification in
the United States only)
 Windows, Doors and Skylights

Lighting Products
 Decorative Light Strings
 Lamps
 Luminaires
Office Equipment
 Computers
 Computer Servers
 Data Center Storage
 Displays
 Imaging Equipment
 Large Network Equipment
 Uninterruptible Power Supplies
Other Products
 Electrical Vehicle Supply Equipment
 Laboratory Grade Refrigerators and Freezers
 Pool Pumps
 Refrigerated Beverage Vending Machines
 W ater Coolers
Water Heaters
 Commercial W ater Heaters
 Residential W ater Heaters—Solar
 Residential W ater Heaters—Non-solar
Partner will deploy ENERGY STAR Certified Set-top Boxes
 Cable, Satellite, and Telecom Service Providers
ENERGY STAR Participation Form

1

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

___________________________________

Role in Company (Hold Ctrl to select multiple)

Title

___________________________________

Company

___________________________________

Address

___________________________________

City

___________________________________

Communications / Marketing / PR
Owner / Executive Management
Government Affairs / Corporate Relations
Legal
Technical / Engineering
Other

State

___________________________________

Role in ENERGY STAR Program

Zip

___________________________________

General (receive all ENERGY STAR correspondence)
Product Specific

Country

___________________________________

Phone

___________________________________

Email

___________________________________

Enter product types (from page 1) that apply to your responsibilities:
Product Lead contact for:

_________________________

Compliance contact for:

_________________________

Unit Shipment Data contact for:

_________________________

Marketing/Communications contact for: _________________________
Specification Development contact for _________________________
(Product Specific Contacts only)

Return completed Participation Form to:

join@energystar.gov 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

Enter product types (from page 1) that apply to your responsibilities:
Product Lead contact for:

_________________________

Compliance contact for:

_________________________

Unit Shipment Data contact for:

_________________________

Marketing/Communications contact for: _________________________
Specification Development contact for _________________________
(Product Specific Contacts only)

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

Enter product types (from page 1) that apply to your responsibilities:
Product Lead contact for:

_________________________

Compliance contact for:

_________________________

Unit Shipment Data contact for:

_________________________

Marketing/Communications contact for: _________________________
Specification Development contact for _________________________
(Product Specific Contacts only)
Return completed Participation Form to:

join@energystar.gov or
ENERGY STAR
c/o ICF
1725 Eye Street, NW, Suite 1000
Washington, DC 20006
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

ENERGY STAR Participation Form

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