WOTC Form - Construction Contractor Services

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WOTC 2022

CCS Online Application WOTC 2022

Work Opportunity Tax Credit Program (WOTC)
Our company participates in the Work Opportunity Tax Credit Program. Your responses to the following questions will be confidential and used only to assist us in complying with the requirements of this program. Your answers will not affect your employment or any benefits you may be receiving. Thank you for your cooperation!
Name
Address*
Street Address City State Zip Code
Phone*
Social Security #*
Date of Birth*
MM slash DD slash YYYY
Position
Wage
Hire Date
MM slash DD slash YYYY
Have you worked for this employer before?*
- Yes
- No
Have you, or any immediate member of your family, EVER received Temporary Assistance to Needy Families (TANF, Welfare)?*
- Yes
- No
Have you, or a member of your family, received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months?*
- Yes
- No
Have you been unemployed for the last 6 months AND received unemployment compensation at ANY TIME?*
- Yes
- No
Have you personally received Supplemental Security Income (SSI) or (SSDI) Supplemental Security Disability Income anytime during the last 2 months?*
- Yes
- No
Have you participated in a rehab program approved by the state, the Ticket to Work program, or the Department of Veterans Affairs.*
- Yes
- No
Are you a Veteran of the United States Armed Forces*
- Yes
- No
Are you a Veteran who received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months.*
- Yes
- No
Are you a Veteran who was unemployed for more than 4 weeks, but less than 6 months, during the past year*
- Yes
- No
Are you a Veteran who was unemployed for more than 6 months during the past year.*
- Yes
- No
Are you a Veteran discharged from active duty within the last 12 months and entitled to compensation for a service connected disability.*
- Yes
- No
Are you a Veteran receiving compensation for a service connected disability who was unemployed for at least 6 months during the last 12 months.*
- Yes
- No
During the last 12 months, were you convicted of a felony or released from prison for a felony.*
- Yes
- No
Hidden
Have you worked for this employer before? – Depreciated
- Yes
- No
Hidden
Have you, or a member of your family, received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months? – Depreciated
- Yes
- No
Hidden
Have you been unemployed for the last 6 months AND received unemployment compensation at ANY TIME? – Depreciated
- Yes
- No
Hidden
Have you personally received Supplemental Security Income (SSI) or (SSDI) Supplemental Security Disability Income anytime during the last 2 months. – Depreciated
- Yes
- No
Hidden
Have you participated in a rehab program approved by the state, the Ticket to Work program, or the Department of Veterans Affairs. – Depreciated
- Yes
- No
Hidden
Are you a Veteran of the United States Armed Forces – Depreciated
- Yes
- No
Hidden
Are you a Veteran who received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months. – Depreciated
- Yes
- No
Hidden
Are you a Veteran who was unemployed for more than 4 weeks, but less than 6 months, during the past year – Depreciated
- Yes
- No
Hidden
Are you a Veteran who was unemployed for more than 6 months during the past year. – Depreciated
- Yes
- No
Hidden
Are you a Veteran discharged from active duty within the last 12 months and entitled to compensation for a service connected disability. – Depreciated
- Yes
- No
Hidden
Are you a Veteran receiving compensation for a service connected disability who was unemployed for at least 6 months during the last 12 months. – Depreciated
- Yes
- No
Hidden
During the last 12 months, were you convicted of a felony or released from prison for a felony. – Depreciated
- Yes
- No
I agree that I am voluntarily providing the information on this form and it is not a condition of employment. My signature authorizes the release of information to the Department of Veterans Affairs, Department of Health and Human Services, Social Security Administration, and other Federal State, and local governments agencies to release information to the client., to verify my eligibility for WOTC. I authorize this form to assist in the completion of IRS Form 8850 and ETA Form 9061. Under penalties of perjury, I declare I provided the information on this form on or before the day a job was offered and that the information I have furnished is, to the best of my knowledge, true, correct, and complete.
Signature
Date
MM slash DD slash YYYY

Largo Office

ED Jarzembowski- Sales Manager

1501 Belcher Rd. S., Suite B-5,
Largo, FL 33771

PHONE: (727) 530-1900

FAX: (727) 530-1922

MOBILE: (469) 515-1955

edjarz@constructioncontractorservices.com
accounting@constructioncontractorservices.com
jryan@constructioncontractorservices.com

Tampa Office

Dana Johnson-Sales Manager

5121 Ehrlich Road, Suite 108
Tampa, FL 33624

PHONE: (813) 885-7002

FAX: (813) 402-2979

MOBILE: (727) 365-4753

djohnson@constructioncontractorservices.com

Orlando Office

Leo Gonzalez- Sales Manager
Michelle Moyeton - Recruiter
Billy Saines - Recruiter

260 Maitland Ave. Suite 1650
Altamonte Springs, FL 32701

PHONE: (407) 286-2222

FAX: (407) 730-2272

MOBILE (Leo): (321) 305-8364

MOBILE (Michelle): (407) 461-3403

MOBILE (Billy): (407) 948-2618

lgonzalez@constructioncontractorservices.com
recruiter@constructioncontractorservices.com
bsaines@constructioncontractorservices.com

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