Home Thanks for visiting WOTCScreener.com. Please use the special web link that you've received from your HR department to continue. Welcome to the pre-employment screening site for: The information provided will be used to determine whether you are an eligible candidate for certain federal and/or state hiring incentive programs, including the Work Opportunity Tax Credit program. Please read each question carefully before answering, and make sure to enter your date of birth and social security number accurately. Please note that answers will be kept confidential and will not affect your ability to receive any government benefits or claims.HiddenLocation Code* HiddenAddress*This field is automatically filled out. Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code HiddenEmployer Name*This field is automatically filled out. HiddenEmployer DBA*This field is automatically filled out. HiddenEmployer State HiddenEmployer EIN Number*This field is automatically filled out. HiddenEmployer Phone*This field is automatically filled out.HiddenEmployer Parent Company This field is automatically filled out.HiddenEmployer Requires Confirmation*This field is automatically filled out. HiddenEmployer screening form text Candidate’s Personal InformationName* First Name Middle Name Last Name HiddenGeocoderAddress* Street Address Address Line 2 (if applicable) City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email HiddenCounty*This field is automatically filled out. HiddenCounty Copied HiddenFormatted Address HiddenZipThis field is automatically filled out. HiddenEmployee State (2) HiddenLat HiddenLong Best Phone Number*Alternate PhoneSocial Security Number (SSN)* Confirm your Social Security Number (SSN)* HiddenSSN Last 4 Date of Birth* MM slash DD slash YYYY HiddenUniqueID HiddenAge (computation)If you are under 16 now but applying to begin work after turning 16, please advise staff, and do not complete this screening.Please enter correct Year of Birth HiddenMatch Duplicate entry. WOTC screening already received. Click next only if the previous entry contained errors. Are you currently employed somewhere other than ?* Yes No Have you ever worked for this employer at any time in the past?* Yes No Are you sure you worked for this very same employer previously?* Yes No Please double check the previous 2 questions- they cannot have different answers. As a "re-hire" for this employer you are not required to continue at this time. You may close this window now. Thank you. Last date of employment MM slash DD slash YYYY HiddenDays since last employmentThank you. Since you have worked for this employer over 1 year ago, there is no need for you to continue filling this screening application. You may close this browser window.Starting WageIf unknown leave blank PositionChoose the title that best describes the job you are applying for--Choose Position--29 Healthcare Practitioners and Technical Occupations31 Healthcare Support Occupations11 Management Occupations13 Business and Financial Operations Occupations15 Computer and Mathematical Occupations17 Architecture and Engineering Occupations19 Life, Physical, and Social Science Occupations21 Community and Social Service Occupations23 Legal Occupations25 Educational Instruction and Library Occupations27 Arts, Design, Entertainment, Sports, and Media Occupations33 Protective Service Occupations35 Food Preparation and Serving Related Occupations37 Building and Grounds Cleaning and Maintenance Occupations39 Personal Care and Service Occupations41 Sales and Related Occupations43 Office and Administrative Support Occupations45 Farming, Fishing, and Forestry Occupations47 Construction and Extraction Occupations49 Installation, Maintenance, and Repair Occupations51 Production Occupations53 Transportation and Material Moving Occupations55 Military-Specific OperationsOtherOther Position Have you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the WORK OPPORTUNITY TAX CREDIT (WOTC)* Yes No or Unsure You answered YES, stating that a State Workforce Agency has provided you with a Conditional Certification for the WOTC Tax Credit Program. If this was done in error, correct your answer above to NO.HiddenIf you answered YES intentionally, please provide your Conditional Certification ID Number here Can you upload the SWA certification form now?* Yes No SWA Certification*Max. file size: 10 MB.Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State?* Yes No or unsure Can you upload proof of your Vocational Rehab-referral now?* Yes No Proof of Vocational Rehab-referred candidate*Max. file size: 10 MB.HiddenName of Vocational Rehabilitation Agency Contact Person* First Last HiddenPhone of Vocational Rehabilitation Agency Contact PersonHiddenEmail of Vocational Rehabilitation Agency Contact Person Were you referred to an employer by an Employment Network under the Ticket to Work Program?* Yes No or Unsure Who were you referred by?* Rehabilitation agency approved by the state Employment Network under the Ticket to Work Program Department of Veterans Affairs HiddenRehabilitation agency approved by the state* Rehabilitation agency approved by the state HiddenEmployment Network under the Ticket to Work Program Employment Network under the Ticket to Work Program HiddenDepartment of Veterans Affairs Department of Veterans Affairs HiddenJob Applicant is a Vocational Rehabilitation (VR) Referral* Yes HiddenAre you at least age 16, but under age 40? YES* Yes No HiddenAre you at least age 16, but under age 40? NO* Yes No HiddenAre you at least age 18, but under age 40? YES* Yes HiddenDOB for q12 on 9061 MM slash DD slash YYYY HiddenDOB for Summer Youth MM slash DD slash YYYY HiddenDOB for SNAP MM slash DD slash YYYY Are you a Veteran of the U.S. Armed Forces?* Yes No HiddenYes-Veteran* Yes Were you referred to this employer by the Department of Veterans Affairs?* Yes No Can you upload your Military Discharge Form DD-214 now?* Yes No Upload DD-214*Max. file size: 10 MB. Are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (formerly Food Stamps) for at least 3 months during the 15 months before you were hired?* Yes or Unsure No Name of Food Stamps Recipient* City of Food Stamps Recipient State of Food Stamps Recipient*--Choose State--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Are you a veteran entitled to compensation for a service-connected disability?* Yes No Were you discharged or released from active duty within a year before you were hired?* Yes No 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?* Yes No Have you been employed for 35 or more hours during any week in the 180-day period prior to today?? Yes No 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?* Yes No SNAP (Food Stamps)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?* Yes or Unsure No HiddenYES - 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?* Yes No HiddenNO- 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?* Yes No OR, have you received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them?* Yes or Unsure No HiddenYES - OR, have you received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them?* Yes No HiddenNO - OR, have you received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them?* Yes No Name of Food Stamps Recipient* City of Food Stamps Recipient State of Food Stamps Recipient*--Choose State--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHiddenUSE- Name of Food stamps Recipient HiddenUSE- City of Food stamps Recipient HiddenUSE- State of Food stamps Recipient TANF (Welfare)Are you a member of a family that received TANF (Welfare) assistance for at least the last 18 months before you were hired?* Yes or Unsure No Are you a member of a family that received TANF (Welfare) 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?* Yes or Unsure No Did your family stop being eligible for TANF (Welfare) assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made?* Yes or Unsure No Are you a member of a family that received TANF (Welfare) assistance for any 9 months during the 18-month period before you were hired?* Yes or Unsure No Have you or any family member received TANF benefits at any time during the past 2 years?* Yes No HiddenQualified IV-A Recipient Yes Name of TANF Recipient* City where TANF benefits were received State where TANF benefits were received*--Choose State--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Were you convicted of a felony during the past 12 months before you were hired?*If you were convicted more than 1 year ago - choose NO. Yes No Date of Conviction* MM slash DD slash YYYY HiddenState of ConvictionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWere you released from prison within 12 months before you were hired?* Yes No Date of Release*Must be within 1 year, otherwise choose 'No' above. MM slash DD slash YYYY Are you in a work release program?* Yes No HiddenWork release Yes HiddenYes- Felon q17 Yes No HiddenNo- Felon q17 Yes No Conviction Type* Federal State Can you provide the name of your Parole Officer?* Yes No Parole Officer's Name* Can you upload your Correction Institution records now?* Yes No Upload Correction Institution Records*Max. file size: 10 MB. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired?* Please Note: SSI/SSDI is Federal Disability income, NOT Social Security payments. Yes No Can you upload your SSI Record or Authorization, or other evidence of SSI now?* Yes No Upload SSI Record or Authorization, or other evidence of SSI*Max. file size: 10 MB.Have you been out of work for at least 27 consecutive weeks prior to today?* Yes No What city did you receive unemployment compensation in? What state did you receive unemployment compensation in?*--Choose State--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingUnemployment Start Date*Please enter last date of employment. MM slash DD slash YYYY Are you or your spouse a member of a Native American Tribe? Yes Additional Questions for New York Youth Hires This employer participates in the NY Youth Hire Program. Please answer the following additional questions to determine eligibility under the program.I currently live in the town, or city limits, of the following target area: Albany Brookhaven Buffalo Hempstead Mount Vernon New Rochelle NYC (5 boroughs) Rochester Schenectady Syracuse Utica White Plains Yonkers Any Other Area Other Area I am currently attending high school* Yes No I am currently enrolled in a High School Equivalency (HSE) program* Yes No Employment Status*I confirm that I meet one or more of the youth categories listed below a. I am currently unemployed. b. I was unemployed prior to completing this application. c. I do not have enough paid work. d. The work I have does not make use of my skills and training. Yes No I am 16 or 17 years old. I have my parent’s or guardian’s permission to submit this application* Yes No HiddenYES I am 16 or 17 years old. I have my parent’s or guardian’s permission to submit this application* Yes No HiddenNo I am 16 or 17 years old. I have my parent’s or guardian’s permission to submit this application* Yes No Parent/Guardian First Name* Parent/Guardian Last Name* Parent/Guardian Phone*Do you have working papers?* Yes No HiddenI am 18 to 24 years old - yes* Yes No HiddenI am 18 to 24 years old - no* Yes No Education Status*Are ANY of the below 5 statements true? • I have a high school diploma. • I have a General Education Development diploma (GED). • I have High School Equivalency (HSE) diploma. • I have satisfactorily completed a Test f or Assessing Secondary Completion (TASC) exam. • I am enrolled in a Treatment Accountability for Safer Communities (TASC) program. Yes No I confirm that I meet one or more of the youth categories listed below* Yes No o I am over 18 years of age and do not have a high school diploma or a General Educational Development (GED) or High School Equivalency (HSE) diploma. o I am a member of a family that is receiving: § Assistance from Temporary Assistance for Needy Families (TANF). § Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps). § Social Security Income (SSI) benefits. o I am receiving a free or reduced-cost school lunch. o I was ref erred to this program by a rehabilitation agency approved by the state, or an employment network under the Ticket to Work Program. o I have served time in jail or prison or I am on probation or parole. o I am pregnant or a parent. o I am homeless. o I am currently or was in foster care or the custody of the Office of Children and Family Services. o I am a veteran. o I am the daughter or son of a parent who is currently in jail or prison, or was in jail or prison within the past two years. o I am the daughter or son of a parent who is collecting unemployment insurance. o I live in public housing or receive housing assistance such as a Section 8 voucher. o I have another risk factor not identified aboveI would like the Department of Labor to contact me by Phone Email Can you upload an image of your driver license now?* Yes No (Note: If it's inconvenient to upload your driver's license, no worries, as it's not required to complete this form. We may request it at a later time.) The address on your driver license should match , , . If it does not, please upload other valid Federal or State proof of address.Drivers License Upload*Max. file size: 10 MB.By signing below, I, the undersigned, agree to adopt the electronic representation of my signature for all purposes when used on documents, as if it was pen-on-paper. Today's Date - 11/09/2025 SignatureHiddenHidden FieldsHiddenWho signed this form* Applicant HiddenIs your address located within an Empowerment Zone?* Yes No HiddenYes - EZ* Yes HiddenIs your address located within an RRC Zone?* Yes No HiddenYes - RRC Updated* Yes HiddenYes - RRC* Yes HiddenDOB - RRC or EZ* HiddenYes- Do you live in an Empowerment Zone or Rural Renewal County (RRC)?* Yes No HiddenNo - Do you live in an Empowerment Zone or Rural Renewal County (RRC)?* Yes No HiddenYes - Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date?* Yes No HiddenNo - Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date?* Yes No Hidden9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORMHiddenUnemployment 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. HiddenI declare that I have been in a period of unemployment since [enter date below] I declare that I have been in a period of unemployment since Hidden8850 Pre-Screening Notice and Certification RequestHiddenCheck here if any of the following statements apply to you. Yes • 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 veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months. • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs. • I am at least age 18 but not age 40 or older and I am a member of a family that: a. Received SNAP benefits (food stamps) for the past 6 months; or b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them. • During the past year, I was convicted of a felony or released from prison for a felony. • I received supplemental security income (SSI) benefits for any month ending during the past 60 days. • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.HiddenCheck here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year. Yes HiddenCheck here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year. Yes HiddenCheck here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year. Yes HiddenCheck here if you are a member of a family that: Yes • Received TANF payments for at least the past 18 months; or • 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; or • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.HiddenCheck here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation. Yes HiddenHIDDDEN YES- 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?* Yes No HiddenHIDDDEN NO Q13- 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?* Yes No HiddenHIDDDEN NO- 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?* Yes No HiddenHIDDEN YES- 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?* Yes No HiddenHIDDEN No- 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?* Yes No HiddenYes- Were you referred by Dept of Veteran Affairs Yes No HiddenNo- Were you referred by Dept of Veteran Affairs Yes No HiddenDate Gave Information MM slash DD slash YYYY HiddenDate was offered job MM slash DD slash YYYY HiddenDate was hired MM slash DD slash YYYY HiddenDate started job MM slash DD slash YYYY HiddenAny TANF Yes HiddenAny Snap Yes HiddenAge 18-39 Yes HiddenAge 16-39 Yes HiddenAge 16-24 Yes HiddenAge 16-18 Yes HiddenSummer Youth Yes HiddenNY Youth Yes HiddenWOTC Eligible- TANF Yes HiddenWOTC Eligible- Long Term TANF Yes HiddenWOTC Eligible- SNAP Yes HiddenIEC Eligible Yes HiddenWOTC Eligible- Long Term Unemployed Yes HiddenWOTC Eligible- SSI Yes HiddenWOTC Eligible- EZ/RRC Yes HiddenWOTC Eligible- Summer Youth Yes HiddenWOTC Eligible- Conditional WOTC Certification Yes HiddenWOTC Eligible- Approved Referral Agency Yes HiddenWOTC Eligible- Ex felon Yes HiddenWOTC Eligible- Veteran Snap Yes HiddenWOTC Eligible- Veteran Short Term Unemployed Yes HiddenWOTC Eligible- Veteran Long Term Unemployed Yes HiddenWOTC Eligible- Veteran Disabled Yes HiddenWOTC Eligible- Veteran Disabled and Unemployed Yes HiddenNY Veteran Eligible- Non Disabled NY Veteran Yes HiddenNY Veteran Eligible- Disabled NY Veteran Yes HiddenWOTC Eligible Yes If candidate is eligible for any WOTCHiddenTodays Date MM slash DD slash YYYY
