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					                                                     American Certification Body Inc.
                                                6731 Whittier Ave, Suite C110, McLean, VA 22101
                                                    Ph: (703) 847-4700, Fax: (703) 847-6888

                                                    Application Form for ENERGY STAR Certification

                    Part 1: Standard Information (required fields are indicated in BOLD text)
                     Company Name:

                      EPA Partner Org ID:
                      OEM Name (if different):
                      Primary Contact Name:
                      Primary Contact E-mail:
                    Test Laboratory:
                      Relationship to Partner:               - Third Party Lab       Partner / OEM In House Lab (First Party Lab)
                      Laboratory Name:
                      Lab Partner Org ID:
                      Laboratory Web URL (if Third Party):
                      Accreditation Body (if accredited):
                      Accreditation Body Online Directory URL:
                      Accreditation Certificate Number / ID:
                      Primary Contact Name:
  Click Here to       Primary Contact E-mail:
Insert Equipment
Ty pe & Sub-Ty pe
                      ENERGY STAR Product Category:                Computers and Electronics
                      Model Number:
                      Product Type:                                                             Specification Version:
                      Product Sub-Type:
                      Serial Numbers of Tested Units:
                    Safety Standards (if required in the ENERGY STAR specification)
                      Safety Standard Reference (if required):
                      Case / File Number:
                    Part 2: Lab Report Instructions

                      An acceptable lab report must be in English, must be clearly legible, and must be in adobe PDF format. The cumulative file
                      size for all lab report documents submitted in support of an ENERGY STAR qualified product submission must be less than
                      10 MB.

                      The lab report must also contain the following information, at a minimum, as per the test procedures specified in the
                      ENERGY STAR program requirements for the appropriate product category.
                           Test procedure name(s)
                           Test date
                           Sample description (e.g., number of products tested)
                           Serial numbers of all tested units
                           Equipment Calibration dates and next due date
                           Environmental conditions (e.g. temperature, humidity)
                           Test results, organized by applicable test procedure section and clearly marked to indicate results that are relevant to
                            ENERGY STAR
                           Test engineer and witness signatures
                    Note 1: This form must be completed and provided with the submission
                    Note 2: This form must also be accompanied by appropriate Product Type “Supplemental Application Form” to be
                             considered complete.
                    Note 3: This form must also be accompanied by Appropriate signed Terms and Conditions. If signed by the Test Lab, and
                             appropriate authorization letter must also be provided. See:


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