District 5 Employer Connect Program

Company Name

Company Address

Company Phone Number

Supervisor Name

Supervisor Title

Supervisor Phone Number

Supervisor Email

Employers eligible to participate in the Employer Connect Program must meet the following criteria, please 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

By signing this form, I confirm that the above is true and correct.

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