• Are you a minor?*
  • Date Of Birth*
     - -
  • Format: (000) 000-0000.
  • Todays Date (Will Autofill)*
     - -
  • Have you worked for this employer before?*
  • If yes, what was your last date of employment?
     - -
  • Are you at least 16, but under age 40?*
  • Are you a Veteran of the U.S. Armed Forces?*
  • Are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired?*
  • Are you a veteran entitled to compensation for a service-connected disability?*
  • Were you discharged or released from active duty within a year before you were hired?
  • Were you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired?
  • Are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired?*
  • Have you received SNAP benefits for at least a 3-month period within the last 5 months but are no longer receiving them?*
  • Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State?*
  • Were you referred to an employer by an employment network under the ticket to work program?*
  • Were you referred to an employer by the department of veteran affairs?*
  • Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired?*
  • Were you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5,1997, ended within 2 years before you were hired?*
  • Did your family stop being eligible for TANF assistance within 2 years before you were hired because of a Federal or state law limited the maximum time those payments could be made?*
  • Are you a family that receive TANF assistance for any 9 months during the 18-month period before you were hired?*
  • Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired?*
  • If yes, was it state or federal conviction?
  • Do you live in an empowerment zone?*
  • Do you live in an empowerment zone and are at least age 16, but not yet 18?*
  • Did you received Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired?*
  • Are you a veteran unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired?*
  • Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months, whether or not consecutive, during the year before you were hired?*
  • Are you an individual who is or was in the period of unemployment that is as least 27 consecutive weeks and for all or part of that period you received unemployment compensation?*
  • Check all that apply
  • I attest, under penalty or perjury, that I am:*

  • Uniform Request Form

    Make sure you scroll inside the form and hit the purple SUBMIT button

  • W4 Tax Filings*
  • Should be Empty: