[NYSERDA] NYSERDA/NYS Clean Heat Program Participation Agreement Signature Form

Thank you for your interest in participating as a contractor in the NYS Clean Heat Program. The authorized company contact must electronically sign this participation agreement.

Please note: Partially completed information cannot be saved, be sure to have all details with you before beginning the form. For the best form completion experience, use the Google Chrome browser. Upon submission, you will receive a confirmation and a tracking number on your screen to print or save. Refer to this tracking number to check on the status of your request.

For complete NYS Clean Heat Program details and eligibility, visit SaveEnergyNY.ny.gov/NYScleanheat.

If you have any questions, please email NYSCleanHeatProgram@nyserda.ny.gov.

* Required field

Contractor Information

Legal Business Name

Is your Legal Business Name different from your Business Name/Disregarded Entity Name?

Yes

Business Name/Disregarded Entity Name

Business Website

Utilities Served (Select all that apply)

Central Hudson & Gas

NYSEG

Con Edison

RG&E

National Grid

O&R

Select the type of contractor you are applying for (Select all that apply)

ASHP Installer

GSHP Installer

GSHP Driller

GSHP Direct Exchange Contractor

GSHP Designer <300,000 Btu/h

GSHP Designer ≥300,000 Btu/h

Phone Number

Phone Extension

Company Email Address

Primary Contact Information

Primary Contact Title

Primary Contact Email

Primary Contact Phone Number

Phone Extension

Your company information will be publicly displayed so end-use consumers can contact you. Should the information provided in the "Primary Contact Information" section be used?

Yes

No, I would like different information displayed publicly

Public-Facing Contact Information

Primary Contact Email

Primary Contact Phone Number

Phone Extension

Uploads

Be certain that NYSERDA and the State of New York are listed on the certificate as additional insured, using the NYSERDA address of 17 Columbia Circle, Albany, NY 12203-6399.

DBA Certificate

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Completed Certificate of Insurance naming NYSERDA and NYS as Additional Insured

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Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I certify that the information submitted in this application is true and accurate to the best of my knowledge.

Tracking ID

You will be provided with a Tracking ID upon submission.