OMB Control No.

2060-0528
Approval Expires September 30, 2019

®
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)

United States
Organization Type: Product Brand Owner (Labeler) Markets where ENERGY STAR
(Hold Ctrl to select multiple) Product Brand Licensee products will be shipped: 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 Home and Building Envelope Products

 Clothes Dryers  Residential Insulation Products
 Clothes W ashers  Roof Products
 Dishwashers  Residential Storm Windows (available for certification in
 Refrigerators and/or Freezers the United States only)
 Residential Dehumidifiers  Windows, Doors and Skylights
 Room Air Cleaners
 Room Air Conditioners Lighting Products
 Decorative Light Strings
Commercial Food Service Equipment
 Lamps
 Commercial Coffee Brewers  Luminaires
 Commercial Dishwashers
 Commercial Griddles Office Equipment
 Commercial Fryers
 Computers
 Commercial Hot Food Holding Cabinets
 Computer Servers
 Commercial Ice Machines
 Data Center Storage
 Commercial Ovens
 Displays
 Commercial Refrigerators and Freezers
 Imaging Equipment
 Commercial Steamers
 Large Network Equipment
 Uninterruptible Power Supplies
Home Electronics
 Audio/Video Equipment Other Products
 Set-top Boxes
 Electrical Vehicle Supply Equipment
 Small Network Equipment
 Laboratory Grade Refrigerators and Freezers
 Telephony
 Pool Pumps
 Televisions
 Refrigerated Beverage Vending Machines
 W ater Coolers
Heating, Ventilation, and AC Products
 Boilers Water Heaters
 Central ACs and Air-source Heat Pumps
 Commercial W ater Heaters
 Commercial Boilers
 Residential W ater Heaters—Solar
 Connected Thermostats
 Residential W ater Heaters—Non-solar
 Furnaces
 Geothermal Heat Pumps
 Light Commercial HVAC Partner will deploy ENERGY STAR Certified Set-top Boxes
 Residential Ceiling Fans  Cable, Satellite, and Telecom Service Providers
 Residential Ventilating Fans
EPA Form No. 5900-33 ENERGY STAR Participation Form 1
 OMB Control No. 2060-0528
Approval Expires September 30, 2019

Primary Contact (if same as signatory contact, leave this blank)

Contact Name ___________________________________ Role in Company (Hold Ctrl to select multiple)

Communications / Marketing / PR
Title ___________________________________
Owner / Executive Management
Company ___________________________________ Government Affairs / Corporate Relations
Legal
Address ___________________________________
Technical / Engineering
City ___________________________________ Other

State ___________________________________

Zip ___________________________________

Country ___________________________________

Phone ___________________________________

Email ___________________________________

Additional Contact 1 (optional)

Contact Name ___________________________________ Role in Company (Hold Ctrl to select multiple)
Communications / Marketing / PR
Title ___________________________________
Owner / Executive Management
Company ___________________________________ Government Affairs / Corporate Relations
Legal
Address ___________________________________
Technical / Engineering
City ___________________________________ Other

State ___________________________________ Role in ENERGY STAR Program

Zip ___________________________________ General (receive all ENERGY STAR correspondence)

Product Specific
Country ___________________________________

Phone ___________________________________

Email ___________________________________

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 2

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

Additional Contact 2 (optional)

Contact Name ___________________________________ Role in Company (Hold Ctrl to select multiple)
Communications / Marketing / PR
Title ___________________________________
Owner / Executive Management
Company ___________________________________ Government Affairs / Corporate Relations
Legal
Address ___________________________________
Technical / Engineering
City ___________________________________ Other

State ___________________________________ Role in ENERGY STAR Program

General (receive all ENERGY STAR correspondence)
Zip ___________________________________
Product Specific
Country ___________________________________

Phone ___________________________________

Email ___________________________________

Additional Contact 3 (optional)

Contact Name ___________________________________ Role in Company (Hold Ctrl to select multiple)
Communications / Marketing / PR
Title ___________________________________
Owner / Executive Management
Company ___________________________________ Government Affairs / Corporate Relations
Legal
Address ___________________________________
Technical / Engineering
City ___________________________________ Other

State ___________________________________ Role in ENERGY STAR Program

General (receive all ENERGY STAR correspondence)
Zip ___________________________________
Product Specific
Country ___________________________________

Phone ___________________________________

Email ___________________________________

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 3