WOTC Form

Company Name*
Company EIN Number
Have you ever worked for this Employer before? Are you a Re-Hire?*
- YES
- NO
Are you under 40?*
- YES
- NO
Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance?*
- YES
- NO

Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?*
- YES
- NO
Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?*
- YES
- NO
If yes to either question, enter Name of Primary Recipient:
And City, State where benefits were received:

Are you a member of a family that received TANF assistance for at least 18 months before you were hired?*
- YES
- NO
Or, did your family stop being eligible for TANF assistance within 2 years before being hired, because you reached the maximum time those benefits can be received?*
- YES
- NO
If yes to either question, enter Name of Primary Recipient:
And City, State where benefits were received:

Name*
First Last
Social Security Number*
Date of Birth*
Email*
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.
Employment Start Date*
Starting Wage*
Position*

If Yes,