Registration Application - Please fill in the following information: (All information submitted will be held confidentially.) click here if you would rather download and fax a printable form Company Information: Company Name: Company Type (janitorial supply distributor, facility service provider, janitorial product distributor, sales rep agency, other): Contact Name: Title: Street Address: City: State: Zip: Phone: Fax: Email Address: Please fill in the Estimated Energy Use of Your Company for Last Calendar Year: Electricity Used in Warehouses and Offices (Kwh): Natural Gas Used in Warehouses and Offices (Therms): Fuel Oil Used in Warehouses and Offices (Gallons): Airplane Travel for Business (Passenger Miles): Delivery Truck and Service Vehicle Fuel Usage in Miles: Gallons & Fuel Type: Business Travel by Car for Sales, Service and by Other Personnel (Vehicle miles):

Registration Fee: $200 Please make the check out to the Leonardo Academy and mail it to: Cleaning Industry Climate Initiative Leonardo Academy 1526 Chandler St. Madison, WI 53711 For Program Details: click here to return to the home page Contact for Additional Information: Cleaning Industry Climate Initiative Leonardo Academy Phone: 608-280-0255 Fax: 608-255-7202 Email: Amanda@leonardoacademy.org Website: www.leonardoacademy.org Address: 1526 Chandler Street Madison, WI 53703