This form is only for organizations classified by the IRS as non-profit (501(c)(3)) at the date of application.
Partially completed applications cannot be saved. Be sure to have all information and details with you before beginning.
Once you submit the application, you will see a tracking number and a screen prompt to print or save it. Refer to the tracking number to check on the application status.
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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
Is your organization classified as a non-profit organization (501 (c)(3)) per the Internal Revenue Service (IRS) at the date of this Application?
STOP! Any completed entries that include a "No" above, the submission will not be accepted.
Organization Address
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
Full Name
Which of the following describes your non-profit organization? Please select all that apply.
Are you filing or has your non-profit organization filed or are you filing a petition under any chapter of the U.S. bankruptcy code within the past 3 years?
Has any principal or officer of your non-profit organization been convicted of a felony within the past 5 years?
Has any principal or officer of your non-profit organization been under disciplinary action (probation, suspension, or termination) within a NYSERDA Program?
Has any principal or officer of your non-profit organization been debarred by any government agency?
Has your non-profit organization’s 501(c)(3) status been previously revoked?
AttestationThe undersigned certifies that:
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
Tracking Number