Essential Business Designation Form

Application for Designation as an Essential Business

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.

(All fields are required unless otherwise noted)

Your Business Information

Please provide information relevant to the business

Name of Business/Organization

Business ID

You can look up your Business ID here

Authorized Contact Person

Your 10 Digit Phone Number

Email Address

Your Business Category

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 here)

Your Business Location:

Please provide information for all location for which you are seeking an exemption

Business Location Address

Number of employees working at the location to perform critical work

Nature of Business Activity at this location

Additional Business Location (Optional)

Please provide information for all locations for which you are seeking an exemption

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)

I certify that the information submitted in this request is true and correct to the best of my knowledge.

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

Date

Connecticut State Connecticut Department of Economic and Community Development