Your Legal Name *

Your name as shown on ID, Contractors please provide your legal business name in the position title box below

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Date *

MM

DD

YYYY

Phone Number *

(###)

###

####

Hire Date *

Please enter your first day at work.

MM

DD

YYYY

Your Filing Status *

Based on your income tax filing

Single

Married filing Separately

Married filing Jointly

Head of household

Widow(er) with dependent child

How would you like to receive your payroll each period? *

Confirm with your employer on your options! If you select direct deposit, please confirm your bank numbers below.

Direct Deposit to my bank account

Paper check or cash from my employer

Work Opportunity Tax Credit Eligibility

Check if any of the following apply to you. If so, you may qualify us to receive a tax credit for hiring you:

Qualified IV-A Recipient: Part of a family that has received TANF assistance for any 9 months during the last 18 months.

Qualified Veteran: A veteran who has faced unemployment for a total of at least 4 weeks in the past year or is entitled to compensation for a service-connected disability.

Qualified Ex-Felon: Hired within a year of felony conviction or release from prison for a felony.

Designated Community Resident: Between 18 to 39 years old, living in an Empowerment Zone or Rural Renewal County.

Vocational Rehabilitation Referral: Referred upon completion of rehabilitative services under the Rehabilitation Act or the Department of Veteran Affairs.

Qualified Summer Youth Employee: Between 16 to 17 years old, working between May 1 and September 15, and residing in an Empowerment Zone.

Qualified SNAP Benefits Recipient: Between 18 to 39 years old and part of a family that received SNAP benefits for the previous 6 months or at least 3 of the last 5 months.

Qualified SSI Recipient: Received Supplemental Security Income benefits within 60 days of the hire date.

Long-Term Family Assistance Recipient: Part of a family that received TANF payments for at least 18 consecutive months, or within two years of the federal/state TANF time limit.

Qualified Long-Term Unemployment Recipient: Unemployed for not less than 27 consecutive weeks and received unemployment compensation during this period.