FlexTech Program (PON 1746)

Thank you for your interest in participating in the FlexTech Program (PON 1746).

This application must be signed by the applicant (customer) submitting the application. Be sure to have all required information readily available before completing this application, since you will not be able to save a partially completed application.

A scope of work & budget are required as part of this application. Please see PON 1746 for details on the scope of work requirements.

You will receive a tracking number and confirmation on your screen to print or save after you have submitted the application.

Please note, a complete application package includes a Consolidated Funding Application (CFA).

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.

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Applicant Information

Applicant Company Name

Applicant Contact Title

Applicant Contact Email

Applicant Contact Phone

Applicant Contact Extension

Applicant Contact Street Address

Applicant Contact City

Applicant Contact State

Applicant Zip Code/Postal Code

Consultant Information

Consultant Company Name

Are you working with FlexTech Consultant?

Consultant Contact Title

Consultant Contact Email

Consultant Contact Phone

Consultant Contact Extension

Consultant Contact Street Address

Consultant Contact City

Consultant Contact State

Consultant Contact Zip Code/Postal Code

Facility Information

Is the primary facility's address the same as the applicant address

Primary Facility Name

Facility Contact Title

Facility Contact Email

Facility Contact Phone

Facility Contact Extension

Primary Facility Street Address

Primary Facility City

Primary Facility State

Primary Facility Zip Code/Postal Code

Facility Sector

Facility Sector - Other

Facility Square Footage

Borough-Block-Lot (BBL) Number

Is the facility contributing to the electric system benefits charge (SBC)?

Per PON 1746, eligible applicants must be New York State facilities that pay into the electric system benefits charge (SBC) on their utility bill.

Electric Utility Name

Electric Utility Account Number(s)

Annual Electricity Cost ($)

Annual Electricity Consumption (kWh)

Peak Summer Electric Demand (kW)

Natural Gas Utility Name

Natural Gas Utility Name - Other

Natural Gas Utility Account Number(s)

Annual Natural Gas Costs ($)

Annual Natural Gas Consumption (therms)

Other Fuel Type

Annual Fuel Costs ($)

Annual Fuel Consumption

Total Annual Energy Costs ($)

Uploads(s)

Scope of Work (SOW) and Budget

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Certification

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I, the Applicant, certify that the facility or lead facility named in the scope of work is interested in technical assistance and is requesting that NYSERDA set aside funds to reimburse the facility, or FlexTech Consultant if applicable, for certain eligible costs, as outlined in the scope of work, in pursuing a project. I certify that the information provided is true to the best of my knowledge As part of this project, NYSERDA will oversee the Service Provider or FlexTech Consultant’s progress and results in completing the scope of work, provide technical review of any applicable report, and be available to address any questions or concerns which arise during the conduct of this project. I, the Applicant, also certify that NYSERDA does not provide any endorsement of the Consultant’s capabilities to provide services outside of the Scope of Work to be conducted pursuant to this agreement. The Customer acknowledges that neither NYSERDA nor its consultant is responsible for assuring that the design; engineering or installation of any recommendation of the technical service is proper or complies with any particular laws (including patent laws), codes, or industry standards. Overall NYSERDA does not make any representations of any kind regarding the results to be achieved or the adequacy or safety of any recommendation. NYSERDA does not endorse, guarantee, or warrant any particular manufacturer or product, and NYSERDA provides no warranties, expressed or implied for any product of service. I, the Applicant, certify the number provided is my correct taxpayer identification number (or I am waiting for a number to be issued to me); 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 (as defined in IRS Form W-9).

By checking this box, I authorize the New York State Energy Research and Development Authority (NYSERDA), and its designated representatives, to access energy billing and consumption data for my site(s). This authorization automatically terminates at the end of five years following the execution date of the Purchase Order associated with this Application. As an authorized representative of the site(s) listed in this Application, I authorize NYSERDA, and its designated representatives, to access and utilize any and all energy consumption information and data. I understand that this information will be used to evaluate energy use patterns for the purpose of measuring energy performance and determining the potential and actual energy savings resulting from evaluated or implemented energy projects. I agree to cooperate with activities designed to evaluate program effectiveness, such as responding to questionnaires and allowing on-site inspection and measurement of installed measures. I understand that NYSERDA is subject to the NYS Freedom of Information Law, Public Officers law, Article 6, and that NYSERDA cannot guarantee confidentiality of any information submitted.

FlexTech Application Number

You will be provided with a FlexTech Application Number upon submission.