Form DOE F 413.28 DOE F 413.28 Partnership Agreement

OMB Control No. 2060-0528
Approval Expires September 30, 2019

ENERGY STAR® Participation Form
for Energy Efficiency Program Sponsors:

Partner Name:
Date:
Partner will participate in the program(s) checked below. Please select only those check boxes relevant for
your organization.
Promote ENERGY STAR as an Energy Efficiency Program Sponsor* in the:









Consumer Product Market
Residential New Construction Market (ENERGY STAR Certified Homes)
Existing Residential Market (Sponsor Home Performance with ENERGY STAR Programs)
Existing Residential Market (ENERGY STAR Verified HVAC Installation)
Existing Commercial Buildings Market
New Commercial Buildings Market
Industrial Market

* Such as states, utilities, or regional program coordinators
Please provide the zip codes that your organization serves to benefit from ENERGY STAR resources. Separate
each zip code with a space.
Zip Codes:

EPA Form No. 5900-33

ENERGY STAR Participation Form

1

OMB Control No. 2060-0528
Approval Expires September 30, 2019

Partner Name:
Date:

Primary Contact (if different than
Signatory Contact listed in the
Partnership Agreement)

Secondary Contact

Secondary Contact

Secondary Contact

Contact Name
Title
Company
Address
City
State
Zip
Country
Phone
Email

Contact Name
Title
Company
Address
City
State
Zip
Country
Phone
Email

Return completed Participation Form to:

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

EPA Form No. 5900-33

ENERGY STAR Participation Form

2