QUALIFIED PRODUCT FORM

 FOR

 SCANNERS

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

(Companies who have joined ENERGY STAR for Scanners 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 scanner 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. 

Tested By: (Name of Firm or Self-Tested)  _____________________________________________________

Please provide any other relevant information:

1. Applicable Characteristics:

2.  Accessories/Other features (e.g., document feeder, transparency adapter, type of scanning software):

    _________________________________________________________

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