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Instructions: Our company participates in a federal tax credit program called the Work Opportunity Tax Credit (WOTC). We ask that you answer the following questions to help determine our company's eligibility for this tax credit should we choose to hire you. Your answers will be kept confidential and will not be used as a condition for employment. This survey should only take a few minutes to complete. Thank you for your time.

First Name

Last Name

Social Security Number

Phone Number

Address

City

State

County

Zip