Employer Connect Program Referral Form

Employer Connect Program

* Company Name

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* Company Address

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* Company Phone Number

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* Supervisor Name

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* Supervisor Title

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* Supervisor Phone Number

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* Supervisor Email

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Employers eligible to participate in the Employer Connect Program must meet the following criteria, please check all that apply:

* Check all that apply

W-9 (The employer must have a valid W-9 form on file)

Small Business - The employer must be classified as a small business according to the Small Business Administration (SBA) guidelines.

Workman’s Compensation - The employer must have worker’s compensation coverage.

W-2 - The employer must issue W-2 forms to their employees.

Impacted by COVID-19 - The employer must demonstrate that their business has been adversely affected by the COVID-19 pandemic.

* Please write a brief explanation of how your business was impacted by COVID-19

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* By checking the box below, you confirm that the above is true and correct.

I confirm that the above is true and correct.