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 as of 6/30/2021 (Full Time)

Total full time employees including full time paid interns as of 6/30/2021

Total employment 6/30/2021 (Part Time)

Total part time employees including part time paid interns as of 6/30/2021

Total employment in Connecticut as of 6/30/2021 (Full Time)

Total employment in Connecticut as of 6/30/2021 (Part Time)

Total employment in Connecticut as of 6/30/2021 (Consultants)

Projected employment in Connecticut as of 6/30/2022 (Full Time)

Projected employment in Connecticut as of 6/30/2022 (Part Time)

Projected employment in Connecticut as of 6/30/2022 (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)

All full time employees including full time interns.

Average Wage Per Employee (Part Time)

All par time employees including full time interns.

Average Wage Per Employee (Consultants)

Average wage for new hires in Connecticut as of 6/30/2021 (Full Time)

Average wage for new hires in Connecticut as of 6/30/2021 (Part Time)

Average wage for new hires in Connecticut as of 6/30/2021 (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

Minority-owned

Yes
No

Veteran-owned

Yes
No

Women-owned

Yes
No

Disabled-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.

The founder/owner is (please select):*

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Native American or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
I do not wish to answer this question.

The founder/owner is (please select):*

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.

The CEO is (please select):*

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Native American or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
I do not wish to answer this question.

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.

CAPTCHA

Connecticut Innovations, Inc.
Fiscal Year Ending June 30, 2021

Employment Information Request Form

Section I

Section II

Section III

Section IV

Connecticut Innovations, Inc. Fiscal Year Ending June 30, 2021

Employment Information Request Form

Section I

Section II

Section III

Section IV

Connecticut Innovations, Inc.
Fiscal Year Ending June 30, 2021