1. What are the utilities Your company buys? 1. What are the utilities Your company buys? Electricity Natural gas Water Others:

Others

2. What are the utilities Your company produces? 2. What are the utilities Your company produces? Cooling Hot water Steam Compressed air Others:

Others

3. Please provide the working schedule (24/24, 2 shifts, 1 shift, 5 days per week, 7 days per week etc.):

4. Assess the level of consumption monitoring: 4. Assess the level of consumption monitoring: General energy meters Internal meters with manual data collection Internal meters with manual data collection Energy consumption and production data integrated Consumption data available to export in Excel

5. Qualify the equipments and installation technology: 5. Qualify the equipments and installation technology: New generation Refurbished or upgraded Classic

6. Assess the level of energy efficiency investments in the last three years: 6. Assess the level of energy efficiency investments in the last three years: Minimal – for maintainance Modest – with limited benefits Significant – with multiple benefits

7. Specify the the business area of Your company:

8. Do You have a target for reducing specific consumption in the next three years? 8. Do You have a target for reducing specific consumption in the next three years? Yes No

9. Do You have an approved budget for energy efficiency solutions? 9. Do You have an approved budget for energy efficiency solutions? Yes No I don't know

10. Do You have an approved budget for CO2 emission reduction projects? 10. Do You have an approved budget for CO2 emission reduction projects? Yes No I don't know

11. Please specify the reasons for Your reasons consultancy request:

12. Your name*:

13. Phone number*:

14. E-mail address*:

15. The company You represent*:

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