Employer Eligibility Review for Climate Justice Fellowship Plus

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

STOP! Any completed entries that include a "No" above, the submission will not be accepted.

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

AttestationThe undersigned certifies that:

1. 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
2. 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
3. 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.