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?
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.Format: (000) 000-0000.
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
Veteran Status
I am a veteran of the U. S. Armed Forces
I am entitled to compensation for a service-connected disability.
I am a veteran discharged or released from active duty within a year before I was hired.
I was unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before I was hired.
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.
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?
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.
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.
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.
I am a member of a family that has received TANF payments for at least the past 18 months
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
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
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.)
Referral
I was referred here by (check all that apply)
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.
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.
Felony
In the past year - Were you convicted of a felony or released from prison after a felony conviction?
Date of conviction

MonthDayYear
Date
Date of release

MonthDayYear
Date
Was this a Federal or State conviction?
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