New Employee Information

New Employee Information
Employer*
Date of Hire*

MonthDayYear
Date
Name*

First NameLast Name
Have you ever previously worked at this location for this employer?*

YesNo
Last Date of Employment At This Location (Estimate)*

MonthDayYear
Date
Starting Position*
Starting Wage*
Per*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Social Security #*
Phone Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
I have received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit

YesNo
Veteran Status
I am a veteran of the U. S. Armed Forces*

YesNo
I am entitled to compensation for a service-connected disability.*

YesNo
I am a veteran discharged or released from active duty within a year before I was hired.*

YesNo
I was unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before I was hired.*

YesNo
I was unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not consecutive) during the year before I was hired.*

YesNo
SNAP
Are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits for at least 3 months during the 15 months before you were hired?*

YesNo
I am a member of a family that received Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) benefits for the 6 months before I was hired.*

YesNo
I / my family has received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for as least a 3-month period during the last 5 months, but we are no longer receiving them.*

YesNo
Name of Primary Recipient of SNAP benefits*

First NameLast Name
City/State of SNAP benefits*

Street Address

Street Address Line 2

CityState

Zip Code
TANF
I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.*

YesNo
I am a member of a family that has received TANF payments for at least the past 18 months*

YesNo
I am a member of a family that has received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years*

YesNo
I am a member of a family that stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum amount of time those payments could be made*

YesNo
Name of Primary Recipient of TANF benefits*

First NameLast Name
Address of TANF Benefits*

Street Address

Street Address Line 2

CityState

Zip Code
Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired? -- (SSI provides monthly payments to people with disabilities and older adults who have little or no income or resources.)*

YesNo
Referral
I was referred here by (check all that apply)

A Vocational rehabilitation agency approved by the stateAn employment network under the Ticket to Work programThe Department of Veterans AffairsNone of the Above
Unemployment
I am/was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period I received unemployment compensation.*

YesNo
What city and state did you receive unemployment compensation in?*

Street Address

Street Address Line 2

CityState

Zip Code
Approximate start date of unemployment:*

MonthDayYear
Date
I declare that I was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period I received unemployment compensation.*

YesNo
Felony
In the past year - Were you convicted of a felony or released from prison after a felony conviction?*

YesNo
Date of conviction*

MonthDayYear
Date
Date of release*

MonthDayYear
Date
Was this a Federal or State conviction?*

FederalState
Signature and Attestation
I attest all the information above is correct to the best of my knowledge and authorize the release of relevant personal information by my employer for WOTC certifications*
Type Your Full Name to Sign Electronically
Signature Date*

MonthDayYear
Date
Should be Empty:

New Employee Information

Veteran Status

SNAP

TANF

Referral

Unemployment

Felony

Signature and Attestation