Work Opportunity Tax Credit Eligibility Survey
Use this form to screen whether a candidate may qualify for Work Opportunity Tax Credit-related eligibility review.
Applicant Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City / State or ZIP Code
Eligibility Screening
Current age
*
Expected first day of work / hire date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Any factor that may affect eligibility?
*
Yes
No
Not sure
Relevant eligibility categories or circumstances
Age 16-17
Age 18-24
Veteran status
Long-term unemployment
Public assistance recipient
Recently incarcerated
Resident of a designated community
Not sure
Other
Work History and Availability
Current employment status
*
Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Retired
Other
Have you worked for this employer before?
*
Yes
No
Not sure
Submit
Should be Empty: