Employer Eligibility Review for Climate Justice Fellowship Plus

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If you have any questions regarding this application or the Climate Justice Fellowship Plus Program, please contact Cjfplus@nyserda.ny.gov.

* Required field

Please select the type of entity that best describes your organization.

Municipality

Non-profit Organization

Public College

Public Library

Public University

Private Non-profit University

Organization Information

Legal Organization Name

Organization Website

Tax Identification Type

Employer Identification Number

Do not submit a Social Security Number to NYSERDA on this form.
If in accordance with the rules on IRS “Form W-9,” your Taxpayer Identification Number is a Social Security Number please complete all other information on this form except for Employer Identification Number. Leave this field blank. In addition to this form, please submit a printed and signed copy of IRS Form W-9 to NYSERDA via mail, attention to Norma Johnston, NYSERDA Finance. Please include your auto-generated Project ID Number on this and any forms submitted by mail to NYSERDA. IRS Form W-9 can be found and printed here: https://www.irs.gov/pub/irs-pdf/fw9.pdf

Primary Contact Information

Title

Phone Number

Phone Extension

Accounts Receivable Contact Information

Title

Phone Number

Phone Extension

Authorized Signatory Contact Information

Title

Phone Number

Phone Extension

Organization Questions

Which of the following describes your organization? Please select all that apply.

My organization is located in the Bronx

My organization is located in Queens

My organization serves the Bronx

My organization serves Queens

Current Size of Organization

Are you filing or has your organization filed or are you filing a petition under any chapter of the U.S. bankruptcy code within the past 3 years?

Yes

Please describe

Has any principal or officer of your organization been convicted of a felony within the past 5 years?

Yes

Please describe

Has any principal or officer of your organization been under disciplinary action (probation, suspension, or termination) within a NYSERDA Program?

Yes

Please describe

Has any principal or officer of your organization been debarred by any government agency?

Yes

Please describe

How did you hear about the Climate Justice Fellowship Plus Program?

Other, please specify:

Please list any NYSERDA funded activities that your organization is participating in, if applicable:

AttestationThe undersigned certifies that:

The number listed in this application is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
I am a U.S. citizen or other U.S. person (defined at the IRS webpage provided below)

For the full instructions, please see the IRS Instructions for the Requestor of Form W-9.

I, the Applicant, certify that the information submitted in this application is true, accurate, and complete to the best of my knowledge and that I have the authority to apply for the New York State Energy Research and Development Authority’s (NYSERDA) Climate Justice Fellowship Plus Program on behalf of the organization which I represent here. I understand that the submission of these materials does not guarantee receipt of funding through any NYSERDA Program. I certify that the entity on whose behalf I submit this application has not intentionally reduced its existing workforce (e.g., terminated an existing employee or given an existing employee a partial work reduction) to hire a new employee under NYSERDA’s Climate Justice Fellowship Plus Program.

I certify that this organization will not discriminate against the unemployed, formerly incarcerated or any other protected class in the selection of an employee for NYSERDA’s Climate Justice Fellowship Plus Program.

Authorized Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to the terms and conditions stated above. I have read and understand the program requirements for the Climate Justice Fellowship Plus Program. By submitting this application, I authorize NYSERDA to add the contact information above to the program mailing lists and share this information with New York State government and other entities doing business on NYSERDA’s behalf. I reserve the right to unsubscribe at any time.

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Tracking Number

You will be provided with a Tracking Number upon submission.