Accounting Employee Information Request - Connecticut Innovations Connecticut Innovations

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 as of 6/30/2023(Full Time)

Total employment in Connecticut as of 6/30/2023(Part Time)

Average Annual Wage Rate Per Employee (Full Time)

Average Annual Wage Rate Per Employee (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

Section V

Name of preparer*

Name Title

Date*

Please contact Lisa Nicoletti with any questions. Email: lisa.nicoletti@ctinnovations.com Tel: 860-258-7852 Fax: 860-563-4877

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Accounting Employment Information Request Form

Section I

Section II

Section III

Section IV

Section V