Sustainable Fee Request Form Fiscal Year 2014-2015 To use this form—Tab from block to block—Do not use the return/enter key. Person making request shall send a printed copy to Carl Gerhold, Chair and email a copy to sustainfeecommittee@apsu.edu Name of Requestor:_______________________ Department/Unit:__________________ Project/Request Title:___________________________ Category of Request: Check one o o o o Energy and Utilities (electric, gas, water, etc) Local Generation (Renewables- solar/wind/etc) Alternative Fuel (hybrid vehicles,bio diesel products etc) Other (Recycling, Environmental, etc) Projects/Fee Requests shall: Provide or demonstrate a specific energy or environmental benefit Be technically and economically feasible. Be cost effective to operate and maintain Be consistent with campus standards and master plan Project/Fee Request Description: (Describe what this project will accomplish, be as specific as possible.) Identify the hardware, software, and physical facilities already available and describe how they will be used to support/augment this project. In your description estimate the number of persons (students, faculty, staff, and community) and describe how they will directly benefit. (maximum 250 words) List any other requirements, not included in this proposal which are essential to its success: (for example, HVAC, Lighting, Data ports, Fiber connections, Room remodeling, staffing needs etc) How does this project address the goals/objectives of the Sustainable Fee Committee? (maximum 150 words) One Time Expenditures (round to the nearest $100) Provide a budget for this project Item Qty Total Cost per Total Cost Name Signature Project Manager _______________________ _________________________ Chair/Director _______________________ _________________________ Signatures are unnecessary for the emailed copy. Send a printed copy to Carl Gerhold of Sustainable Fee Committee and email a copy to sustainfeecommittee@apsu.edu If you have attachments, please send the attachments with both printed and emailed forms.