• Have you ever worked for this Employer before? Are you a Re-hire?
• Yes
  No

• Are you under age 40?
• Yes
  No

• Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance?
• Yes
  No

• Are you a Veteran of the US Armed Forces?
  No
  Yes
  
  If yes:
  • Are you a member of a family that received SNAP (Food Stamps Benefits)?
    No
    Yes
  • Are you entitled to compensation for a service-connected disability?
    No
    Yes
  • Were you discharged from active duty within the last year?
    No
    Yes
  • Were you unemployed for a combined total of 6 months before you were hired?
    No
    Yes

• Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?
• Yes
  No

• Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?
• Yes
  No

• If yes to either question, enter Name of Primary Recipient:

• And City, State where benefits were received:

• Are you a member of a family that received TANF assistance for at least 18 months before you were hired?
• Yes
  No

• Or, did your family stop being eligible for TANF assistance within 2 years before being hired, because you reached the maximum time those benefits can be received?
• Yes
  No

• If yes to either question, enter Name of Primary Recipient:

• And City, State where benefits were received:

• Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days, before you were hired?
• Yes
  No

• Were you convicted of a Felony during the year before you were hired?
• Yes
  No

Were you referred to an employer by

• - A Vocational Rehab Agency approved by the state?
• Yes
  No

• - An Employment Network under the Ticket to Work Program?
• Yes
  No

• - The Dept. of Veteran Affairs?
• Yes
  No