wotc form

Applicant Info

First Name, Middle Name*

Last Name *

Gender*

Male

Female

Street Address*

City *

State *

Zip Code*

Apt, Suite, PO Box #

Contact Number

Email Address

Did you ever work for this employer before? *

Yes

Do you have a work start date?*

Yes

Work Start Date*

Date you applied for Job*

Date of Birth*

Social Security # *

Position Applied*

Desired Wage

WOTC Questionnaire

Are you a member of a family that received SNAP Benefits (Supplemental Nutrition Assistance Program), or Food Stamps: *

Yes

Are you a member of a family that received TANF (Temporary Assistance for Needy Families), or Cash Benefits: *

Yes

Did you receive SSI Benefit (Supplemental Security Income) for any month ending within 60 Days before you were hired? *

Yes

Have you received a conditional certification from a State Workforce Agency (SWA), or a participating local agency for the Work Opportunity Credit? *

Yes

Have you been unemployed for at least 27 consecutive weeks, and collected any Unemployment Compensation during that time? *

Yes

Are you a Veteran of the US Armed Forces *

Yes

Were you Convicted of a Felony, or released from prison during the year before you were hired? *

Yes

Do you live in a Rural Renewal Community or an Empowerment Zone? *

Yes

Have you received any type of Vocational Rehabilitation services within the past two years? *

Yes

Sign and Submit

Employee Signature*

The information contained in this application is correct and to the best of my knowledge.

By signing this form, I hereby authorize any agency, organization, Social Security Administration, Department of Veterans Affairs, or individuals, to supply verification of information as may be needed to determine tax credit eligibility to my employer, employer representative (TC Services USA, Inc. dba WOTC.com), or the Department of Labor. I also understand that my responses are used, in part or in full, to complete the IRS Form 8850 and any other documents pertaining to the WOTC Program, and that modifications can be made by my employer, or employer representative, in order to enable the verification screening process as required by some states. This information will not in any way affect my employment.

Today's Date*