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

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 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
Date Format: MM slash DD slash YYYY
Minority owned
- Yes
- No
Veteran owned
- Yes
- No
Women owned
- Yes
- No
Section IV
# Patents pending
# Patents approved
Name of preparer*
Name Title
Date*
Date Format: MM slash DD slash YYYY
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