Healthcare Facility Energy Compliance Application
Facility Information
Facility Name
Facility Type
Hospital
Clinic
Nursing Home
Other
Address
City
State
ZIP Code
Contact Information
Contact Name
Title
Phone
Email
Energy Compliance Details
Annual Energy Usage (kWh)
Compliance Standard
ASHRAE
LEED
Other
Description of Energy Efficiency Measures
Certification and Attestation
Certifying Official Name
Certifying Official Title
Date