中美合同能源管理示范项目申报表

1、中美合同能源管理示范项目申报表申报单位名称项目名称项目领域工业【】，商业建筑【】，公共建筑【】，公共基础设施【】，其他【】项目地址建筑面积（建筑项目填写；平方米）项目实施时间预计完工时间项目类型分享型【】，保证型【】，能源费用托管型【】，其他【】主要改造对象（至少三个系统）项目总投资主要融资方式项目单位改造前年综合能源消费量（请使用能耗单位）预计改造后年综合能源消费量（请使用能耗单位）项目参与方信息（中方项目至少一个美方参与机构，美方项目至少一个中方参与机构有更多参与机构的，可增加表格填写）节能服务公司名称联系人电话& 邮件用能单位名称联系人电话& 邮件技术供应商名称联系人电话

2、& 邮件融资机构名称联系人电话& 邮件项目基本情况描述：包括但不限于项目实施方介绍、项目总体状况、项目改造措施、项目投资额、项目效果等项目创新点：对示范项目的创新部分进行描述，包括但不限于技术创新、融资模式创新、合同模式创新、M&V创新、运营管理创新等项目预期节能效果：描述预期年节能量、节能率以及评估与验证（M&V）方式申报单位授权代表信息姓名职务邮箱电话手机传真通信地址及邮编申请单位承诺：我单位承诺上述信息属实；我单位承诺：如果项目经过工作组专家审核确定为备选示范项目，将每季度按要求向中国国家发改委、美国国务院和美国能源部指定单位联系人（中国节能协会服务产业委

3、员会禹网霞 ；太平洋西北国家实验室太平洋西北国家实验室Meredydd Evans 和谭清 ）递交项目进展报告。 单位盖章 年 月 日AppendixUS-China EPC Pilot Project Application FormName of Applying CompanyProject NameProject SectorIndustry【】，Commercial Building【】,Public Building【】， Public infrastructure【】Project LocationBuilding Area (Building Project; m2)Proje

4、ct Start DateAnticipated Completion DateProject modelShared savings【】, guaranteed savings【】, outsourcing【】, other【】Main Retrofit Systems (at least 3 systems)Investment AmountMain Financing MethodEnergy Consumption Before Retrofit(in original energy units)Anticipated Energy Consumption After Retrofit

5、 (in original energy units)Information of those involved with the project（Each project should have US-China elements, At least one ESCO and one Energy Consuming Company, additional institutions could also be added）ESCOContactPhone & EmailHost Company ContactPhone & EmailTechnology Provider C

6、ontactPhone & EmailFinancing InstitutionContactPhone & EmailBasic introduction of the project：Including but not limited to project implmentator's profile, project's overview (including facility type/purpose, average annual energy use, 

7、;retrofit measures planned (specify an integrated approach that will retrofit at least 3 systems), investment amount needed in the project, project expected results, etc.Innovation in the project：Describe innovation within the project, including but not limited to innov

8、ation in technology, financing method, contracting models(like guaranteed savings or other innovative model), measurements and verification(m=M&V), etcPredicted energy saving results of the project：Describe the yearly energy saving, energy saving percentage and their basis，M&V approach Autho

9、rized Representative InformationNamePositionEmailPhoneCellFaxPostal Address and CodeApplicants Promise：My company promises the information above are truthful;If the project is selected as a pilot project, my company promise to share and report project information quarterly to the government organizers NDR