Industrial Assessment Center
Mississippi State University
P.O. Drawer ME
210 Carpenter Engineering
Mississippi State, MS 39762
Jeremy Childers
Telephone (662) 325-3765
FAX (662) 325-0102
Dr. R. E. Forbes
Mrs. Mary C. Emplaincourt
Dr. B. K. Hodge
APPLICATION FOR AN INDUSTRIAL ASSESSMENT
Please release copies of appropriate utility bills to authorized personnel of the
Mississippi State University IAC.
Company Name:
SIC Code:
________________________________________________________
_____________________________________________________________
Is the facility located within 150 miles of Starkville?
___________________________
Approximate Annual Gross Sales:
__________________________________________
Approximate Annual Production:
___________________________________________
Number of Employees:
__________________________________________________
Approximate Square Footage of Facility
Approximate Annual Energy Cost:
______________________________________
_________________________________________
Do you have in-house expertise in energy use or conservation?
Approximate Waste Disposal Cost:
Contact Person:
___________________
_________________________________________
________________________________________________________
Company Mailing Address:
_________________________________________________
_____________________________________________
Phone Number:
Fax Number:
________________________________________________________
___________________________________________________________
Once the MSU IAC verifies that you qualify for an assessment, a member of the IAC
staff will contact the facility to arrange a site visit and forward a questionnaire
requesting additional information concerning energy, waste, and production.
Industrial Assessment Center
Mississippi State University
P.O. Drawer ME
210 Carpenter Engineering
Mississippi State, MS 39762
Jeremy Childers
Telephone (662) 325-3765
FAX (662) 325-0102
Dr. R. E. Forbes
Mrs. Mary C. Emplaincourt
Dr. B. K. Hodge
UTILITY BILLS RELEASE AUTHORIZATION
Please release copies of appropriate utility bills to authorized personnel of the Mississippi
State University IAC.
Company:
Location:
Person Authorizing Release:
Signature:
Date:
___________________________________________________________
___________________________________________________________
_______________________________________________
___________________________________________________________
___________________________________________________________
Electric Utility:
Location:
Phone Number:
Account Number(s):
_________________________________________________________
___________________________________________________________
________________________________________________________
_____________________________________________________
Gas Utility:
Location:
Phone Number:
Account Number(s):
___________________________________________________________
___________________________________________________________
________________________________________________________
_____________________________________________________
Water Utility:
Location:
Phone Number:
Account Number(s):
__________________________________________________________
___________________________________________________________
________________________________________________________
_____________________________________________________
Waste Handling Company:
Location:
Phone Number:
Account Number(s):
__________________________________________________________
___________________________________________________________
________________________________________________________
_____________________________________________________