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The statement(s) must address the areas listed below and be signed by the Chairman/CEO, either formally or in effect. Indicate whether the statement(s) has only been adopted at this time or currently is being implemented. See the "Cradle to Cradle Certification Program" overview document for example statements.Labor Practices*Corporate and Personal Ethics* IntegrityCompetitive behaviorSupplier relationshipsCustomer ServiceLocal CommunityIs your company exploring certification/accreditation by another organization for labor practices at all facilities in which the finished product is assembled/manufactured? The labor practice assessment system must feature the characteristics listed below. If true, then acknowledge by signing below. Provide contact information for the assessment organization. See the "Cradle to Cradle Certification Program" overview document for suggested systems.  Internationally Accepted*Intra-industry or Inter-industry Framework!Minimum Components to be AssessedFreedom of association  and collective bargaining]List the labor practice criteria for which your company has begun to gather data for initial self-assessment of all product assembly facilities. Provide all/some of the available data (preferably in the format used in the assessment system) in the table below or attach the certifying/accrediting organization's form/additional sheets, as necessary."As an authorized representative of the applicant company, I verify that all responses provided above are correct, based upon our currently available data."JUnder the header "Assessments of Watershed Health on the EPA web page for your watershed (see above), determine whether each facility withdraws water from or discharges effluent to a water source listed as "impaired." Also, identify the impairment concerns near each facility and indicate how the facility impacts these concerns. Water UseaComplete the attached "Cradle to Cradle Certification Applicant Data Form -- Materials Appendix."If the product contains both biological and technical nutrient materials, describe how materials are marked and attached to one another to simplify post-use disassembly.Percent of Total Use/Contact Information for Assessment Organization(Certification/Accreditation OrganizationLabor Practice CriterionCriterion Category5*This area must be addressed within the statement(s). Current Data Child labor Forced laborHealth and safetyDiscriminationDiscipline/harassment Working hours CompensationContact InformationDate:Contact Person:Mailing Address: Telephone:Fax:Email:1)2)3)4)5)6)7)8)9)10)#Additional InformationApplicant Company:Product Trade Name: Product Type:&Contact Person and Contact InformationA)B)C)D)E)F)G)H)I)J) Printed NameSignature and DateTitleBiological metabolismTechnical metabolismBoth-Material Reutilization/Design for Environment Materials*Manufacturer: (if not 'Applicant Company')EnergyWaterAquifer Surface water ReclaimedOther (please specify)Additional commentsWhere is the source located?/What are the other major demands on the source? Industrial Municipal Ecosystem Facility Name Facility A Facility B Facility C Facility D Facility EFacility LabelGeographical Location Facility A: Facility B: Facility C: Facility D: Facility E:If your product contains materials assessed by MBDC as 'Red' for human and environmental health, then attach written plan (including budget and timeline) for the eventual phase-out/replacement of these ingredients.EFor which of the following metabolisms has the product been designed?Name of WetlandCubic Meters Per Year)Major / Minor Water User Within WatershedDifference (unaccounted for)Calculation Method UsedInline MeteringProduction AllocationIs each facility considered a major or minor user of water relative to other users within its watershed? Contact the local or regional water authority for this information.Subtotal (water use)!Total water purchased or obtained*Process use: parts and mixing vat cleaning&Domestic: faucets, toilets and showers LandscapingLeaks (detected)Food preparation: dishwasher)Cooling: tower make-up and boiler make-up/Once-through cooling: air compressors and pumps,General washing, sanitation, and maintenanceProcess and Equipment UseCleaningMetal finishingPaintingDyeing and finishingPhoto processingOther Facility Support!Product fluming (water transport)Cooling and HeatingSingle-pass coolingCooling towers/chillers Boiler, hot water, steam systems Outdoor Uses Air washersBoiler scrubberSanitary and Domestic Personnel Ramsar Wetland Site? (Yes / No)VPlease provide any additional comments or data for use within your product evaluation.@Process Water (liters/kg of product; or indicate correct units)K)L)M)Social ResponsibilityPosted in facilitiesCompany newsletterEmployee handbookCompany intranetEmployee trainingSIndicate all locations where the statement(s) is/are available for employee review.QIndicate all locations where the statement(s) is/are available for public review.Public website Annual report Press releaseExternal newsletterMarketing materialsRHas your company been certified/accredited for labor practices within all assembly/manufacturing facilities? If true, then acknowledge by signing below. Attach documentation from assessment organization. Also, submit copies of future approvals as they are received (for regular verification updates, as required by the assessment system).YFor each facility, list the NPDES permit number and name of designated water coordinator.NPDES Permit NumberAttach process flow diagrams for the product assembly/manufacturing process, possibly including mass balance information for inputs and outputs.Embodied in Products Landscaping Floor washing IrrigationAir emission wet scrubbers" Particulate emission controlBuilding washing Decorative fountains/pondsQuality assurance testing Vehicle washing LaboratoriesWastewater treatmentPrimary SIC / NAICS Number:Secondary SIC / NAICS Number: Toilets Urinals Faucets Showers Kitchen Cafeteria uses Dishwashers Ice machines Faucets/taps Consumption Medical0Facility A: (or indicate correct facility label) Example Facility:_List all facilities in which the finished product is assembled/manufactured (i.e., facilities in which suppliers' materials/components are combined to create the finished product). Please attach additional sheets, if necessary. Note: You will use the 'Facility Label' identifiers to report facility-specific data in other sections of this application.If all ingredients previously assessed as 'Red' have been removed from your product and the revised formulation has been fully assessed by MBDC and no other 'Red' ingredients are included, then acknowledge by signing below.If the product is designed to be used within building interiors, then attach product emission testing results from an approved lab, for either ASTM D5116 (small chamber) or ASTM D6670 (large chamber).*Assembly/manufacturing energy is the portion of the facility's total energy use which can be attributed to assembling the finished product, plus an appropriate allocation of energy used in other facility operations.;Percentage of Assembly Energ< y Derived from Renewable SourceWindBiomass HydroelectricSolarOther (specify){For each facility, what percentage of assembly/manufacturing energy* is derived from renewable sources (e.g., wind, biomass, hydroelectric, solar)? Renewable energy can be obtained through on-site production, direct purchase or purchase of Green-e certified renewable energy certificates. If applicable, attach copies of renewable energy certificates or contracts with providers. If not all of the energy for the product's final assembly/manufacturing (within each facility) is derived from renewable sources, then attach a copy of a plan for supplying that energy via current solar income, including a timeline, measurable goals and milestones. Signature-Questions for Silver, Gold and Platinum TiersIf post-use product recovery and material reutilization systems are not currently in place, then attach a copy of your well-defined plan for those activities, including scope, timeline, budget and partners.If post-use product recovery and material reutilization systems are currently in place and operating, then attach documentation of this process and how used products and materials are converted into new products.Question for Platinum Tier Only)Question for Gold and Platinum Tiers Only If post-use product recovery and material reutilization (i.e., composting/recycling) systems are not currently in place and in-depth planning for those systems has not occurred, then sign below to acknowledge that your company is developing a plan to establish such systems in the future.nFor the following questions, please submit average energy data based on the previous six months of operations.qPlease complete the following fields in order for MBDC to calculate the product's Nutrient (Re)utilization Score.>(i.e., intention is for product to be composted following use)=(i.e., intention is for product to be recycled following use)(i.e., intention is for product to be separated into biological and technical materials following use, and for these to be composted and recycled)(MBDC will complete)Percent of the product:Recycled contentMaterial which is either plant- or animal-based and considered rapidly renewable (i.e., can be regrown and harvested within a "minimal" amount of time).MBDC will use the material data in Section 1 to determine the recyclable percentage. Based on the Federal Trade Commission's definition; requires a commercially-available recycling technology for the specific material. Calculation:NMaterials which are considered compostable based on the DIN or ASTM standards. Compostable RecyclableMaterial which is dervied from a post-consumer or post-industrial/pre-consumer recycled source (please indicate). Recycled content will only be counted if it does not contain any problematic inputs (e.g., recycled content PVC will not count).Nutrient (Re)utilization ScoreAttach all supplier data forms, including the quantities and sources of their manufacturing energy, which must be completely derived from current solar income. Questions for Platinum Tier OnlyIf all of the energy for the product's final assembly/manufacturing (within each facility) is derived from renewable sources, then acknowledge by signing below. If applicable, attach copies of renewable energy certificates or contracts with providers.}For each facility within which the finished product is assembled/manufactured, how much energy* is used to assemble/manufacture the product? Calculate these values either based on metering of the specific production line or allocating full facility energy use to the portion of manufacturing represented by this product. Please enter values and units in the table on the next page. Attach your company's set of principles or guidelines that will inform your facility s future strategies for protecting and preserving the quality and supply of water resources. See the "Cradle to Cradle Certification Program" overview document for example principles.,Question for Silver, Gold and Platinum Tiers3For each facility in which your finished product is assembled/manufactured, complete the following questions, adapted from the Global Environmental Management Initiative's Water Source Profile Form . Copy and complete the questions for each facility. oIs any assembly facility located within or adjacent to a Ramsar listed wetland ?On If all of the energy for the entire product's manufacturing (within each final assembly facility, as well as each supplier's facility) is derived from renewable sources, then acknowledge by signing below. If applicable, attach copies of renewable energy certificates or contracts with providers. Note the applicant company can purchase certificates equal to the total energy used to produce all components.Water source(s)#What type of water source(s) is it?Using the US EPA website , identify the watershed within which each assembly facility operates.E Watershed NameUSGS Cataloging Unit Number.Withdraws/Discharges to Impaired Water Source?Local Impairment ConcernsImpacts by Facility.Conduct a facility-wide water audit for each product assembly/manufacturing facility. For water balance calculations, use the attached "Cradle to Cradle Certification Applicant Data Form -- Water Appendix." Copy and complete the table and appendix form for each product assembly/manufacturing facility./Water Coordinator: Name and Contact InformationFor each facility, how much process water is used to assemble/manufacture the product (i.e., all water for the assembly process and other facility operations, on a per-product basis)? Calculate these values either based on metering of the specific production line or allocating full facility water use to the portion of manufacturing represented by this product. Please enter values and their units in the table on the next page. Does each finished product assembly/manufacturing facility meet or exceed EPA and state water quality regulations for discharges, under EPA s National Pollution Discharge Elimination System (NPDES)? Each facility must document it has not been designated as "Significant Noncompliance (SNC)" or "non-major / minor" chronic violator by its state for a period of two years prior to application date. If true, then acknowledge by signing on the next page and attach documentation for each facility. (If any finished product facility is listed under either violation categories, the applicant must wait one year before applying for Gold certification.)What measures to conserve water resources have been taken at the facility for the following areas, as identified in North Carolina's "Water Efficiency Manual for Commercial, Industrial and Institutional Facilities" ?*Questions for Gold and Platinum Tiers OnlySDescribe water conservation improvements that have been implemented during the last five years at each assembly facility for the areas listed in Question I above. Indicate the water use reductions in terms of liters/kg or gal/lb of finished product. Atta< ch documentation regarding the measures, technologies or process changes implemented.Describe innovative projects for reclaiming or recycling water resources or preserving water quality that have been implemented at each assembly facility. Below are some examples of innovative processes. Attach documentation for each facility. Living machines Constructed wetlandsAlternative Treatment Systems!Novel Demand Reduction StrategiesPersonnel education programsFlow control technologiesWaterless urinalsLow-flow fixturesUse of gray water0Reclamation and Recycling of Process Waste Water*Water quality matched to task requirementsRWater cascaded to lower-quality tasks to maximize use prior to treatment/discharge$Non-point Source Pollution Reduction Green roofs7Capture and storage of roof/landscape run-off for reuseDrainage swalesLPorous pavement to capture rainwater for landscape irrigation/gray water use<Native/xeriscape plantings to eliminate landscape irrigationComposting toilets<Attach all supplier data forms for material ingredient data.OHave your suppliers adopted statements regarding their social and ethical performance goals? In addition, have suppliers implemented any necessary workplace improvements in order to better achieve those goals? If true, then acknowledge by signing below. 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