Tax Credit Survey

Thank you for your interest in employment with our company. All of our locations participate in a number of federal, state and local government initiatives to help individuals obtain employment.

We request that you complete the following brief survey to determine if your employment would qualify our Company to receive certain corporate tax credits or incentives.

The information provided on this survey will not affect your employment, your wages or taxes and will only be used to determine and document our Company’s eligibility for a tax credit or incentive. This information will NOT be used for any other purposes. We greatly appreciate your participation in this survey.

FIRST NAME:		LAST NAME:
	First name is required.		Last name is required.
SOCIAL SECURITY NUMBER:	- -	DATE OF BIRTH: (MM/DD/YYYYY)	- -
	First three digits are missing. Second two digits are missing. Last four digits are missing. First three digits must be numbers. Second two digits must be numbers. Last four digits must be numbers.		Month is missing. Day is missing. Year is missing. Year must be 4 digit and numeric. Year must be 4 digit and numeric.
CURRENT ADDRESS
STREET ADDRESS 1:
	Street address 1 is required.
STREET ADDRESS 2:
CITY:		STATE:
	City is required. Letters Only		State is required.
COUNTY:		ZIP CODE:
	County is required.		Zip code is required. Not a valid zip code.
	A location is required.