Company profile form - Connecticut Innovations Connecticut Innovations

General Company Information

Legal Company Name*

Address*

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

Email*

Phone*

Contact Name*

First Last

Secondary Contact Name

First Last

Federal ID#-Enter 0 if n/a*

Please provide reason if no Federal ID# is available:

Connecticut State Tax ID Number

NAICS Code*

Date Incorporated*

Type of Entity (LLC, Ccorp, Inc. etc.)*

Where Incorporated

If not incorporated please state legal structure of business:

Product Description/Technology Area*

How did you hear about Connecticut Innovations? (i.e., website, personal contact, other, etc..)*

Company Financial Information

Total amount of funding requested from Connecticut Innovations:*

Other funding sources are:

The total amount of funding:*

12 month revenues $*

Date (period reported i.e. 12/31/19)*

Company Ownership/Management

Have any of the persons associated with this company been party to any criminal, civil, or administrative proceedings, or charged with any offense other than a minor traffic violation? If yes, please attach an explanation.*

Yes
No

File

Max. file size: 50 MB.

Have any of their persons associated with this company been through bankruptcy, receivership or compromise settlement? If yes, please attach an explanation.*

Yes
No

File

Max. file size: 50 MB.

Has the company, or its principals, been party to or threatened with any civil lawsuits of a material nature other than dissolution of marriage within the past five years? If yes, please attach an explanation.*

Yes
No

File

Max. file size: 50 MB.

Are there any past due taxes to the state or a municipality?*

Yes
No

Have you filed your Annual Report with the Secretary of State? (This applies to Connecticut companies only.)*

Yes
No

Is the company minority-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 owner is (please select):

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White

Is the company woman-owned?:*

Yes
No

Is the company veteran-owned?:*

Yes
No

Is the company disabled-owned?:*

Yes
No

Please provide the following information about your senior management team:

Name*

First Last

Email*

Phone*

Name*

First Last

Email*

Phone*

Job Information

Total in Connecticut (current)*

Other locations*

Average Wage

Total in Connecticut (No. in year 1)

Other locations

Average Wage

Total in Connecticut (No. in year 2)

Other locations

Average Wage

Total in Connecticut (No. in year 3)

Other locations

Average Wage

Consent*

I agree to the following:

ANY FALSE STATEMENT MADE HEREIN IS PUNISHABLE AS A CLASS A MISDEMEANOR UNDER SECTION 53a-157b OF THE CONNECTICUT GENERAL STATUTES.

I hereby certify that, to the best of my knowledge, the preceding information is true and complete. I further certify that I will report, in writing to Connecticut Innovations, Incorporated, any changes to the information contained herein.

NO FEE OR COMMISSION SHOULD BE PAID TO ANY THIRD PARTY FOR CI FUNDING. NO THIRD PARTY CAN INFLUENCE OR INCREASE THE BENEFITS AVAILABLE UNDER CI FUNDING. CONNECTICUT INNOVATIONS WORKS EXCLUSIVELY WITH ELIGIBLE COMPANIES; NOT WITH THIRD PARTIES.

Signature*

Name

First Last

Title

Date

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Company Profile

General Company Information

Company Financial Information

Company Ownership/Management

Job Information