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Accounting Employment Information Request Form
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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 @ 6/30/2020 (Full Time)
Total employment in Connecticut @ 6/30/2020 (Part Time)
Projected employment in Connecticut for FYE 6/30/2021 (Full Time)
Projected employment in Connecticut for FYE 6/30/2021 (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 @ 6/30/2020 (Full Time)
Average Annual Wage Rate for new hires in Connecticut @ 6/30/2020 (Part Time)
Section III
Industry (select one)
Aerospace
Agriculture
Bioscience
Insurance and Financial Services
Manufacturing
Retail
Restaurant
Service
Software/Information Technology
Tourism
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
Date Format: MM slash DD slash YYYY
Minority-owned
Yes
No
Veteran-owned
Yes
No
Women-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.
Race/Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Section V
Name of preparer
*
Name
Title
Date
*
Date Format: MM slash DD slash YYYY
ATTN: LISA NICOLETTI 470 James Street, Suite 8, New Haven, CT 06513 Tel: 860-258-7852 Fax: 860-563-4877
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