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.This field is hidden when viewing the formLocation Code*This field is hidden when viewing the formAddress*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 This field is hidden when viewing the formEmployer Name*This field is automatically filled out.This field is hidden when viewing the formEmployer DBA*This field is automatically filled out.This field is hidden when viewing the formEmployer StateThis field is hidden when viewing the formEmployer EIN Number*This field is automatically filled out.This field is hidden when viewing the formEmployer Phone*This field is automatically filled out.This field is hidden when viewing the formEmployer Parent CompanyThis field is automatically filled out.This field is hidden when viewing the formEmployer Requires Confirmation*This field is automatically filled out.This field is hidden when viewing the formEmployer screening form text Candidate’s Personal InformationName* First Name Middle Name Last Name This field is hidden when viewing the formGeocoderAddress* 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 This field is hidden when viewing the formCounty*This field is automatically filled out.This field is hidden when viewing the formCounty CopiedThis field is hidden when viewing the formFormatted AddressThis field is hidden when viewing the formZipThis field is automatically filled out.This field is hidden when viewing the formEmployee State (2)This field is hidden when viewing the formLatThis field is hidden when viewing the formLongBest Phone Number*Alternate PhoneSocial Security Number (SSN)*Confirm your Social Security Number (SSN)*This field is hidden when viewing the formSSN Last 4Date of Birth* MM slash DD slash YYYY This field is hidden when viewing the formUniqueIDThis field is hidden when viewing the formAge (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 This field is hidden when viewing the formMatchDuplicate 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 This field is hidden when viewing the formDays 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.This field is hidden when viewing the formIf you answered YES intentionally, please provide your Conditional Certification ID Number hereCan 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. This field is hidden when viewing the formName of Vocational Rehabilitation Agency Contact Person* First Last This field is hidden when viewing the formPhone of Vocational Rehabilitation Agency Contact PersonThis field is hidden when viewing the formEmail 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 This field is hidden when viewing the formRehabilitation agency approved by the state* Rehabilitation agency approved by the state This field is hidden when viewing the formEmployment Network under the Ticket to Work Program Employment Network under the Ticket to Work Program This field is hidden when viewing the formDepartment of Veterans Affairs Department of Veterans Affairs This field is hidden when viewing the formJob Applicant is a Vocational Rehabilitation (VR) Referral* Yes This field is hidden when viewing the formAre you at least age 16, but under age 40? YES* Yes No This field is hidden when viewing the formAre you at least age 16, but under age 40? NO* Yes No This field is hidden when viewing the formAre you at least age 18, but under age 40? YES* Yes This field is hidden when viewing the formDOB for q12 on 9061 MM slash DD slash YYYY This field is hidden when viewing the formDOB for Summer Youth MM slash DD slash YYYY This field is hidden when viewing the formDOB for SNAP MM slash DD slash YYYY Are you a Veteran of the U.S. Armed Forces?* Yes No This field is hidden when viewing the formYes-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 RecipientState 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 This field is hidden when viewing the formYES - 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 This field is hidden when viewing the formNO- 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 This field is hidden when viewing the formYES - 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 This field is hidden when viewing the formNO - 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 RecipientState of Food Stamps Recipient*--Choose State--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingThis field is hidden when viewing the formUSE- Name of Food stamps RecipientThis field is hidden when viewing the formUSE- City of Food stamps RecipientThis field is hidden when viewing the formUSE- 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 This field is hidden when viewing the formQualified IV-A Recipient Yes Name of TANF Recipient*City where TANF benefits were receivedState 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 This field is hidden when viewing the formState 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 This field is hidden when viewing the formWork release Yes This field is hidden when viewing the formYes- Felon q17 Yes No This field is hidden when viewing the formNo- 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 AreaI 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 This field is hidden when viewing the formYES I am 16 or 17 years old. I have my parent’s or guardian’s permission to submit this application* Yes No This field is hidden when viewing the formNo 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 This field is hidden when viewing the formI am 18 to 24 years old - yes* Yes No This field is hidden when viewing the formI 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 - 10/15/2026 SignatureThis field is hidden when viewing the formHidden FieldsThis field is hidden when viewing the formWho signed this form* Applicant This field is hidden when viewing the formIs your address located within an Empowerment Zone?* Yes No This field is hidden when viewing the formYes - EZ* Yes This field is hidden when viewing the formIs your address located within an RRC Zone?* Yes No This field is hidden when viewing the formYes - RRC Updated* Yes This field is hidden when viewing the formYes - RRC* Yes This field is hidden when viewing the formDOB - RRC or EZ*This field is hidden when viewing the formYes- Do you live in an Empowerment Zone or Rural Renewal County (RRC)?* Yes No This field is hidden when viewing the formNo - Do you live in an Empowerment Zone or Rural Renewal County (RRC)?* Yes No This field is hidden when viewing the formYes - Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date?* Yes No This field is hidden when viewing the formNo - Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date?* Yes No This field is hidden when viewing the form9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORMThis field is hidden when viewing the formUnemployment 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. This field is hidden when viewing the formI 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 This field is hidden when viewing the form8850 Pre-Screening Notice and Certification RequestThis field is hidden when viewing the formCheck 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.This field is hidden when viewing the formCheck 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 This field is hidden when viewing the formCheck 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 This field is hidden when viewing the formCheck 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 This field is hidden when viewing the formCheck 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.This field is hidden when viewing the formCheck 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 This field is hidden when viewing the formHIDDDEN 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 This field is hidden when viewing the formHIDDDEN 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 This field is hidden when viewing the formHIDDDEN 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 This field is hidden when viewing the formHIDDEN 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 This field is hidden when viewing the formHIDDEN 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 This field is hidden when viewing the formYes- Were you referred by Dept of Veteran Affairs Yes No This field is hidden when viewing the formNo- Were you referred by Dept of Veteran Affairs Yes No This field is hidden when viewing the formDate Gave Information MM slash DD slash YYYY This field is hidden when viewing the formDate was offered job MM slash DD slash YYYY This field is hidden when viewing the formDate was hired MM slash DD slash YYYY This field is hidden when viewing the formDate started job MM slash DD slash YYYY This field is hidden when viewing the formAny TANF Yes This field is hidden when viewing the formAny Snap Yes This field is hidden when viewing the formAge 18-39 Yes This field is hidden when viewing the formAge 16-39 Yes This field is hidden when viewing the formAge 16-24 Yes This field is hidden when viewing the formAge 16-18 Yes This field is hidden when viewing the formSummer Youth Yes This field is hidden when viewing the formNY Youth Yes This field is hidden when viewing the formWOTC Eligible- TANF Yes This field is hidden when viewing the formWOTC Eligible- Long Term TANF Yes This field is hidden when viewing the formWOTC Eligible- SNAP Yes This field is hidden when viewing the formIEC Eligible Yes This field is hidden when viewing the formWOTC Eligible- Long Term Unemployed Yes This field is hidden when viewing the formWOTC Eligible- SSI Yes This field is hidden when viewing the formWOTC Eligible- EZ/RRC Yes This field is hidden when viewing the formWOTC Eligible- Summer Youth Yes This field is hidden when viewing the formWOTC Eligible- Conditional WOTC Certification Yes This field is hidden when viewing the formWOTC Eligible- Approved Referral Agency Yes This field is hidden when viewing the formWOTC Eligible- Ex felon Yes This field is hidden when viewing the formWOTC Eligible- Veteran Snap Yes This field is hidden when viewing the formWOTC Eligible- Veteran Short Term Unemployed Yes This field is hidden when viewing the formWOTC Eligible- Veteran Long Term Unemployed Yes This field is hidden when viewing the formWOTC Eligible- Veteran Disabled Yes This field is hidden when viewing the formWOTC Eligible- Veteran Disabled and Unemployed Yes This field is hidden when viewing the formNY Veteran Eligible- Non Disabled NY Veteran Yes This field is hidden when viewing the formNY Veteran Eligible- Disabled NY Veteran Yes This field is hidden when viewing the formWOTC Eligible Yes If candidate is eligible for any WOTCThis field is hidden when viewing the formTodays Date MM slash DD slash YYYY
