Air-Source Heat Pump (ASHP) Program Participating Installer Application

Thank you for your interest in participating in the Air-Source Heat Pump (ASHP) program. Complete the following fields and upload the required documentation. You will not have the capability to save partially completed applications so please have all required information with you before completing this application. If you have any questions, call 1-800-284-9069. After submitting, you will receive a confirmation on your screen to print and save. Visit nyserda.ny.gov/PON3653 for full details. 

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.

* Required Field

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 Section II. 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 Joanne Sullivan, 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  

Certificate of Insurance*
Provide a copy of your Certificate of Insurance that satisfies the requirements set forth under Article 4 of the ASHP Program Participation Agreement. Acceptable Certificate of Insurance samples can be found here: https://www.nyserda.ny.gov/-/media/Files/Programs/ASHP/Certificate-of-Insurance-Samples.pdf.

Certificate of Training *
Provide a copy of your ASHP Manufacturer Sponsored Installation Training Certificate or correspondence from ASHP Manufacturer that indicates you have been trained. 

I certify that:

1. The number shown on this form 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, found here: https://www.irs.gov/instructions/iw9/ar02.html

By signing this document, I attest that I have the authority to represent and bind my company to the terms and conditions enumerated in this application, the Air Source Heat Pump (ASHP) Program Manual, found here: https://portal.nyserda.ny.gov/CORE_Solicitation_Document_Page?documentId=a0lt0000000frivAAA, and the Air Source Heat Pump (ASHP) Program Partnership Agreement, found here: https://portal.nyserda.ny.gov/CORE_Solicitation_Document_Page?documentId=a0lt0000000frj0AAA.