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For Zone Use Only ID # State of New York Empire Zones Program APPLICATION FOR JOINT CERTIFICATION OF AN EMPIRE ZONE BUSINESS ENTERPRISE Please answer all questions carefully and completely. Original signatures are required on the SIGNATURE PAGE. Submission of an incomplete application or one with incorrect or fraudulent information will result in a delay of approval for, or a denial of certification. Submit application directly to the local Zone to obtain the approval of the Zone Certification Officer (ZCO). Failure to follow this procedure will result in the delay of approving your application. If additional space is required to complete this application, please use the Form EZ-2. SECTION A: Description of Applicant Business 1. Name of Organization (use legal name) 2. Form of Organization (check one) Corporation Partnership S. Corporation LLC Non-Profit Proprietorship 3. Nature of Business (check one) Retail Commercial/ Service Manufacturing Other Type of good or service to be produced 4. Date of Formation or Incorporation (mm/dd/yyyy) _ _ / _ _ / _ _ _ _ 5. NAICS 6. Is this business (check all that apply) Women-Owned Minority-Owned Existing Business New Business 7. Period of which business taxable year is based Calendar year Fiscal year If Fiscal Year, indicate period SECTION B: Business Location and Contact Information 8. Name of Empire Zone in which business is (will be) located 9. Is this business (check one) Currently in Zone Not in Zone, located In pending Zone boundary revision (NOTE: See condition for forwarding application to ESD in Section F: Local Certification Officer’s signature block.) Moving Into Zone From Elsewhere In NYS (Outside an Empire Zone – attach shift resolution from municipality) Another Empire Zone in NYS Outside of NYS 10. Location in Zone Street City Zip 11. Date this location was placed in the Zone (mm/dd/yyyy) _ _ / _ _ / _ _ _ _ 12. Mailing address (if different than above) Street/P.O. Box City State Zip 13. Designated contact for applicant business (see instructions) Name of Company Street City State Zip Phone ( ) - Fax ( ) - E-mail SECTION C: Business Identification Numbers – Refer to instructions before completing Section C. 14. Federal Employer Identification Number (FEIN)//Taxpayer Identification Number 15. NYS Unemployment Insurance (UI) Registration Number 16. Workers’ Compensation Policy Number If no policy number, is the applicant self-insured? Yes No Insured by NYSIF Yes No Name of Carrier 17. Disability Insurance Policy Number If no policy number, is the applicant self-insured? Yes No Insured by NYSIF Yes No Name of Carrier 18. Is the applicant using a identification number of another business entity or common paymaster for unemployment? Yes No If Yes, complete and attach EZ-3. 19. Will any of the retained jobs or new jobs created be for leased employees? Yes No If Yes, complete and attach EZ-3. 20. Is there a predecessor company?(see instructions) Yes No If Yes, please provide, Name of Company FEIN EZ-1 (10-03) 1 of 3 ---PAGE BREAK--- EZ-1 (10-03) 2 of 3 For Zone Use Only ID # SECTION D: Certification History and Application Criteria 21 Has this business previously applied for certification and been denied on grounds of violating NYS or federal worker protection laws? Yes No 22. Has this business previously received certification that has been revoked? Yes No If yes, what was the basis for the revocation? How has the problem/issue been remedied/resolved? 22a. Total number of full-time equivalent (FTE) employees in the Zone (excluding general officers) using the average of the last four quarters ending on March 31st, June 30th, September 30th and December 31st, for the calendar year preceding the date the applicant signs the application. 22b. Total number of FTE employees in the Zone as of the date the applicant signs the application. 23. Does the applicant intend to create new positions or make new capital investments in the Zone? Yes No If you answered yes to question 23 please answer questions 23a through 23d. a. Projected number of new FTE positions (excluding general executive officers) to be created in the Zone during the first two years of certification for positions in which a substantial part of the work will be performed in the Zone. (NOTE: Use month and year in which the applicant signs the application as the reference point.) b. Average starting hourly wage for these positions. $ c. Date to begin hiring. / d. Will any of the new FTE positions in the Zone be positions transferred from other establishments owned or operated by the applicant that are located in other municipalities, towns or villages in the state? Yes No e. Projected fixed asset investment (in to be made in the Zone facility during the first two years of certification. (NOTE: Use month and year in which the applicant signs the application as the reference point.) 24. If the projected number of new FTE positions to be created or the capital investments to be made in the Zone will occur more than two years after certification, indicate the number of new positions, amount of capital investments and the expected date for these events to occur. Number of New FTE Positions: Expected Date To Begin Hiring (mm/year): Capital Investments: Expected Date To Begin Investments (mm/year): 25. Briefly explain the basis for the applicant’s claims to hire new employees or make new capital investments (See instructions). 26. If the applicant business answered no to question 23, does the applicant intend to prevent a loss of jobs in the Zone? Yes No 27. TO BE COMPLETED BY THE ZONE. If the applicant is not projecting new FTE positions to be created nor capital investments to be made in the Zone, provide a statement in support for this application indicating how the certification of this business will enhance the economic climate of the Zone. ---PAGE BREAK--- EZ-1 (10-03) 3 of 3 SIGNATURE PAGE For Zone Use Only ID # SECTION E: Acknowledgments And Agreements By Authorized Representative of the Applicant Organization As the responsible officer, (print or type name) I hereby: a. Acknowledge the company’s obligation to provide 90-day written notice to the Commissioner of Economic Development, the local Empire Zone certification officer, the local Empire Zone administrative board, the local Zone Capital Corporation, and the employees of the business enterprise of any intent to close or partially close a facility within the Zone. For the purposes of this agreement, “closing” means the permanent termination of the business facility’s operation, and “partial closing” means the permanent termination of a portion of the business facility’s operations that will immediately reduce the workforce by 50 employees or 50 percent over a one-year period, whichever is greater; b. Agree to list for the purposes of recruitment all openings (exclusive of general executive offices) for jobs and training programs in the zone facility with the local job services office of the New York State Department of Labor, or demonstrate to the satisfaction of the Commissioner of Economic Development and the Commissioner of Labor what other comparable methods will be used to recruit targeted individuals for such openings; c. Agree to submit an annual report to the local Empire Zone Certification Officer on a form to be prescribed by the Commissioner of Economic Development, including but not limited to, data on the extent to which the certified facility has met the projections set forth in this application and, if applicable, the reason it has not; and, d. Authorize the Commissioner of Labor to disclose to employees of the New York State Departments of Labor and Economic Development and the local Empire Zone certification officer all records of employment filed by the company in making Unemployment Insurance reports and contributions required by the Unemployment Insurance Law and all records of delinquencies. The use of information and records released pursuant to this authorization shall be limited to the government purposes relating to certifying the company for Empire Zone benefits and incentives under General Municipal Law Article 18B, monitoring compliance with program criteria, and reviewing the performance of the zone programs. e. Acknowledge that if business enterprise, or its agent, during the three years preceding the submission of this application for certification, engaged in a substantial violation or a pattern of violations of laws regulating unemployment insurance, workers’ compensation, public work, child labor, employment of minorities and women, safety and health, labor standards, or other laws for the protection of workers as determined by final judgment of a judicial or administrative proceeding may result in denial of certification. Signature Title Date _ _ / _ _ / _ _ _ _ State of New York ) County of ) On the day of (month) 20 (year), before me personally appeared (name) to me known, who being by me duly sworn, did depose and say that he/she resides at (address) that he/she is the (title) of (business entity) , the business entity described herein which executed the foregoing instrument; and that he/she signed his/her name thereto by the authority granted by such business entity. Notary Signature Date SECTION F: Record of Receipt and Approval/Disapproval of Application for Joint Certification of an Qualified Empire Zone Enterprise To be completed by local Empire Zone Certification Officer. I hereby Approve Disapprove this application for joint certification of an Empire Zone Enterprise. If the applicant will be located in the zone by a pending zone boundary revision, this certification application must not be forwarded by the local Empire Zone Certification Officer to the Commissioner of Economic Development until the boundary revision has been officially approved by such commissioner. Signature Title Date _ _ / _ _ / _ _ _ _ To be completed by the Commissioner of the NYS Department of Labor. I hereby Approve Disapprove this application for joint certification of an Empire Zone Enterprise. Signature Date _ _ / _ _ / _ _ _ _ To be completed by the Commissioner of the NYS Department of Economic Development. I hereby Approve Disapprove this application for joint certification of an Empire Zone Enterprise. Signature Date _ _ / _ _ / _ _ _ _