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Please submit this form to apply for status as an essential business. If approved, your business will be allowed to remain open during the statewide suspension of in-person business activities.
Name of Business/Organization
Authorized Contact Person
Your 10 Digit Phone Number
How would you describe your business's primary activity?
Why do you feel your business should be classified as an 'essential business'? Also tell us how you plan to maintain employee safety during the COVID-19 crisis. (see recommended guidelines from the CDC
Business Location Address
Number of employees working at the location to perform critical work
Nature of Business Activity at this location
If you have more than 2 business locations, please specify additional number of business locations (optional)
By sending this request, I certify under penalty of false statement, Connecticut General Statutes section 53a-157b
, that the information that I have provided herein is true and accurate.
Name of Authorized Applicant