QUALIFIED PRODUCT FORM

FOR

PRINTER, FAX, PRINTER/FAX, & MAILING MACHINES

ENERGY STAR^® Product Information Form for Use by ENERGY STAR Labeled Printer/Fax Partners

(Companies who have joined ENERGY STAR for Printer/Fax 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 printer/fax 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.

1.       Which of the following best describes this product  (choose only one):

Stand Alone Printer_____ 
Printer/Fax Combo_____ 
Stand Alone Fax Machine_____ 
Mailing Machine _____

2.       Does this model meet all of the requirements of the Energy Star Printer/Fax Agreement — Version 2.1? (Effective until 31 October 2000)   

Yes_____          No_____

3.       Does this model meet all of the requirements of the Energy Star Printer/Fax Agreement — Version 3.0?     

Yes_____          No_____          

4.       For Agreement — Version 3.0, does the product qualify under 

Tier 1___ Tier2___  NA ___

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

Tested By: (Name of Firm or Self Tested)  __________________________________________________

Please select all that apply:

1.       FOR PRINTERS, PRINTER/FAX MACHINES, FAX MACHINES, AND MAILING MACHINES

    __________Monochrome                ________Color

    __________Standard                      ________Wide Format

    __________Laser                            ________A3 Impact

    __________Ink Jet                          ________LED

    __________Thermal Transfer          ________Dot Matrix

    __________Dot Matrix                   ________Other, Specify________________________

1a.  Does this product have duplexing capabilities? 

            Yes______      No______       Optional Accessory______

2.       FOR FAX MACHINES:

Does this product have a PC interface (i.e., can a fax be sent via this product through a computer)?
        Yes____          No____                         Optional_____

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

4.       Please list or describe any additional features below.

_______________________________________________________________