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Self-Certify your business

Thank you for protecting the health and safety of your workers and customers and being committed to our united fight against COVID-19. By submitting this form, you are certifying that your business is complying with all health and safety standards. After completing this process, your business will be added to the public listing of self-certified businesses, and you will receive branded material by mail to display at your business.

Before you fill out the information below, you must read and review the following health and safety guidelines:

HEALTH AND SAFETY REQUIREMENTS

* Denotes a required field

Business Sector *

*Choose a sector that closely aligns to your business

Business Name *

*Please specify your registered business name

Business Address *

*If you have multiple locations, you need to submit a form per location

Street Address *

Apartment, Suite, Unit, Building, Floor, etc.

City *

State *

County *

Zip Code *

Maximum Occupancy *

*Please enter fire code Maximum Occupancy

Women-Owned Business

Is this a Women-Owned Business (i.e. 51% or higher women ownership)?

Minority Business Enterprise

Is this a MBE-Minority Business Enterprise (i.e. 51% or higher minority ownership)?

Veteran-Owned Business

Is this a Veteran-Owned Business (i.e. 51% or higher veteran ownership)?

Business Email Address *

*Provide an active email address where you receive all business correspondence

Confirm Email Address *

*Please enter your email address

Business Phone Number *

*Provide a phone number for your business communication in the format 1234567890

Rules and Guidelines

click on the link to view the rules and guidelines to open and operate your business.

Self-Certification

As a representative of this business, I understand that the most important consideration will be the health and safety of the employees and customers of my represented business. I have read these rules and will ensure strict adherence to the protocols listed.

I understand that if this business is found in violation of the requirements listed above, this certification may be revoked and this business may be removed from the public listing of self-certified businesses.

By clicking this box, I am attesting to the fact that the information provided is accurate. False statements made herein are punishable under the penalty for false statement set out in C.G.S. Section 53a-157b.

Business Authorized Representative Name

Provide the name of the owner or individual representing the business

First Name *

Last Name *

Date

Once submitted, please check your email for the confirmation link to complete the self-certification process. If you haven't received an email shortly, please check your junk or spam folder.

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Self-Certify your business

Self-Certify Your Business