QUALIFIED PRODUCT FORM

FOR

COPIERS

ENERGY STAR^® Product Information Form for Use by ENERGY STAR Labeled Computer Partners

(Companies who have joined ENERGY STAR for Copiers by signing the Memorandum of Understanding)

You may use this form to report only those products that are sold under your company’s brand name.  If your firm sells its models to another company that uses its own brand name, that company must join the program and report its own products.  Information from this form will be added to the list of Energy Star qualified copier products. Please copy this form and fax one for each qualifying product model to Energy Star, Environment and Development Foundation, 886-3-5820231.

Company Name:__________________________________

  (As listed in MOU)
Product Contact Information

(For public requesting product information)

Tel:________________  Fax:_____________________

E-mail: ______________________________________

Note: Please provide the following information on the configuration of the tested model ONLY.

Please Describe the Type of Copier (check the appropriate boxes below):

Please answer the following questions:

1. Does this product company with the specifications provided in Agreement — Version 3.0

(which incorporates Amendments 1 and 2)?   
Yes ___ No ____

2. Does this Copier model have duplexing capabilities?    
Yes _____   No _____   

2.a.  Is duplexing an optional accessory
   Yes _____   No _____

2.b.  Is the duplex unit set at “default-to-duplex” when shipped?
Yes _____   No _____

3. What type of fusing unit does this Copier use?
______________________________

4. If this model is listed with the US General Services Administration, please include its schedule number and special item number____________________________________________________

Please list or describe any additional features below.

_________________________________________________________