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Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

Signature—All Applicants Must Sign



Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.

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MM slash DD slash YYYY

FOR DISPLAY ONLY

Quick Inquiry

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Full Name

Schedule Consultation

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Full Name