QUALIFIED PRODUCT FORM

   FOR

       MONITOR/TERMINALS

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

(Companies who have joined ENERGY STAR for Monitors 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 monitor 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 Configuration:                                         Monitor____________                     Terminal______________

Please complete all the fields below.

Please indicate the monitor/terminal’s display technology: (If other, please describe.)       

Note applicable characteristics for tested configuration: (Add description where necessary on another page.)

Tested By: (Name of Independent Testing Firm or Self-Tested) ___________________________ Date Tested:_____________

Please answer the following questions:

1.       Does this product qualify with all conditions of the new Monitor MOU Version 3.0 effective 7/1/99?        
Yes____      No _____          If no, why? __________________________________________________________________
(New products released on or after this date must qualify with the new MOU Version 3.0.)

2.Please describe any additional features in the space below, or on another page.

__________________________________________________________________