Authorization Form For A Third Party Representative To Submit Certification Report(S) - U.s Department Of Energy

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AUTHORIZATION FORM for a Third Party Representative to Submit Certification Report(s) –  
Consumer Products & Commercial and Industrial Equipment 
 
The purpose of this form is for a regulated party to authorize a third party to prepare and submit 
certification reports to DOE under the provisions of 10 C.F.R. § 429.12(g). 
 
To complete this form: 
1. Type in the information for the company official responsible for submitting certification reports. 
2. Type in the information for the third party representative – the party who will be using CCMS to 
submit reports (often the OEM, a trade group, or a test laboratory). 
3. Print the form, then sign and date the compliance statement. 
4. Form submittal method: 
Scan and Email signed copy to: 
CCMS.Support@ee.doe.gov 
 
Part I: Company (e.g., Manufacturer); Authorization 
 
Name of Company Official who authorizes said third party representation (“Authorizing Official”): 
_____________________________________________________________________________________ 
Title: ________________________________________________________________________________ 
Company: ____________________________________________________________________________ 
Address: _____________________________________________________________________________ 
_____________________________________________________________________________________ 
Email Address: ________________________________________________________________________ 
Telephone Number: ____________________________________________________________________ 
Facsimile Number: _____________________________________________________________________ 
 
I, the Authorizing Official identified above, authorize the following third party organization to submit 
certification reports to the U.S. Department of Energy on behalf of my company: 
Third Party Organization: __________________________________________________________ 
Address: _______________________________________________________________________ 
______________________________________________________________________________ 
Email Address: __________________________________________________________________ 
Telephone Number: ______________________________________________________________ 
Facsimile Number: _______________________________________________________________ 
Product Type(s): _________________________________________________________________ 
1 
 

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