Employment 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

CT Tax Reg. #

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)

Total employment in Connecticut @ 6/30/2020 (Consultants)

Projected employment in Connecticut for FYE 6/30/2021 (Full Time)

Projected employment in Connecticut for FYE 6/30/2021 (Part Time)

Projected employment in Connecticut for FYE 6/30/2021 (Consultants)

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

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

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

Average Wage Per Employee (Full Time)

Average Wage Per Employee (Part Time)

Average Wage Per Employee (Consultants)

Average wage for new hires in Connecticut @ 6/30/2020 (Full Time)

Average wage for new hires in Connecticut @ 6/30/2020 (Part Time)

Average wage for new hires in Connecticut @ 6/30/2020 (Consultants)

Section III

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

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):

Minority-owned

Yes
No

Veteran-owned

Yes
No

Women-owned

Yes
No

Disabled-owned

Yes
No

Section IV

# Patents pending

# Patents approved

Name of preparer*

Name Title

Date*

Contact Stepheni Harpin @ stepheni.harpin@ctinnovations.com or 860-258-7880 with questions.

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Connecticut Innovations, Inc.
Fiscal Year Ending June 30, 2020

Employment Information Request Form

Section I

Section II

Section III

Section IV

Connecticut Innovations, Inc. Fiscal Year Ending June 30, 2020

Employment Information Request Form

Section I

Section II

Section III

Section IV

Connecticut Innovations, Inc.
Fiscal Year Ending June 30, 2020