Form

Point of Contact (who is making this request)*

CLA Client Number (if applicable)

Company Name*

If filling out on behalf of a WOTC client, please list their company name.

State/Province (2-Letter) of Company Headquarters*

FEIN*

Federal Employer Identification Number

Company Location(s)*

Please list the physical addresses for all company locations so that we may screen for additional credit opportunities.

Company Type*

Company Year End*

Yearly Employees Hired*

Current Employee Count*

Company Representative (First Name)*

This is the individual who will be filling out the Form 9198 for the organization (Employer Representative Declaration Form)

Company Representative (Last Name)*

This is the individual who will be filling out the Form 9198 for the organization (Employer Representative Declaration Form)

Company Representative Email*

Company Representative Phone Number*

Does the company use a payroll provider?

Next Steps (select any of the following)*

New Hire Onboarding Process Details

Please select the preferred method to screen new hire WOTC eligibility*

You can select more than one:

Electronic (Survey Link)

Manual (Paper Questionnaire)

Mobile (Paper Questionnaire with QR code)

Unsure

Would you like a Spanish version of the preferred method to screen new hire WOTC eligibility?*

Additional Comments