New York Youth Jobs Program - Business Certification

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Are you a PEO Member?

Yes

PEO Name:

PEO FEIN:

PEO Responsible Officer Name:

Business Name:

FEIN:

Business Address:

Business Address Line 1:

Business Address Line 2:

Worksite Location:

Worksite Location same as Business Address

Worksite Location Address Line 1:

Worksite Location Address Line 2:

My business is within a reasonable commuting distance of these target areas (Check all that apply)

Albany

Buffalo

Mount Vernon

New Rochelle

New York City (5 boroughs)

Rochester

Schenectady

Syracuse

Utica

White Plains

Yonkers

Additional Area

Brookhaven

Hempstead

Additional Area

Recertifying for New York Youth Jobs Program

My business is new to the New York Youth Jobs Program

My business is already certified in the New York Youth Jobs Program or New York Youth Works

Contact Name:

Job Title:

Phone Number:

Extension:

Fax Number(Optional):

Are you a third party representative of the business?

Yes

If you are a third party submitting this application on behalf of the business, please provide the following contact information for a representative at the business.

Business Representative Name:

E-mail:

Phone Number:

Extension:

Preferred Contact Method by Department of Labor:

Phone

E-mail

Department of Labor

New York Youth Jobs Program - Business Certification

Terms of Service Agreement