Accounting Employee Information Request

Section I

Name of Company*

Federal EIN Number

Contact Name*

Contact Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

Phone

Fax Number

Email

Section II

(full time = over 35 hours/week; part time = less than 35 hours/week)

Total employment in Connecticut @ 6/30/2021 (Full Time)

Total employment in Connecticut @ 6/30/2021 (Part Time)

Projected employment in Connecticut for FYE 6/30/2022 (Full Time)

Projected employment in Connecticut for FYE 6/30/2022 (Part Time)

Number of employees eligible for benefits (i.e. health insurance) Full Time

Number of employees eligible for benefits (i.e. health insurance) Part Time

Average Annual Wage Rate Per Employee (Full Time)

Average Annual Wage Rate Per Employee (Part Time)

Average Annual Wage Rate for new hires in Connecticut @ 6/30/2021 (Full Time)

Average Annual Wage Rate for new hires in Connecticut @ 6/30/2021 (Part Time)

Section III

Industry (select one)

Describe nature of business

Section IV

NAICS Code

NAICS (North American Industry Classification System) This is a six-digit number to classify businesses by type of activities in which they are engaged.

Gross revenue ($) for latest year ended

Date fiscal year ended

Minority-owned

Yes
No

Veteran-owned

Yes
No

Women-owned

Yes
No

Disabled-owned

Yes
No

To better understand the companies we work with and to further our goal of diversity in our business endeavors, we are also requesting the following information about company owners. This question is optional.

The founder/owner is (please select):*

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Native American or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
I do not wish to answer this question.

Section V

Name of preparer*

Name Title

Date*

ATTN: LISA NICOLETTI 470 James Street, Suite 8, New Haven, CT 06513 Tel: 860-258-7852 Fax: 860-563-4877

CAPTCHA

Accounting Employment Information Request Form

Section I

Section II

Section III

Section IV

Section V