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Pre-Employment
Survey

Thank you for accepting your position with SOS WAX! This pre-employment survey helps us determine if you qualify for various benefits programs. Your honest responses are important and will not affect your employment status. All information provided will be kept confidential and used solely for benefits determination.

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- Step 1 of 10

Basic Information

Position *

Full Name *

First

Last

Date of Birth *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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SNAP / Food Stamps

Have you or a family member ever received food stamps or SNAP? *

Yes
No
Unsure

Are you currently receiving? *

Yes
No

Primary Recipient Information (if not you)

First

Last

City / State

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Temporary Assistance for Needy Families (TANF)

Have you or a family member ever received TANF? *

Yes
No
Unsure

Primary Recipient Information (if not you)

First

Last

City / State

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Military Service

Are you a veteran of the U.S. Armed Forces? *

Yes
No

Discharge Date *

Branch *

Army
Navy
Air Force
Marines
Coast Guard
Space Force

Unemployment Period Last Year? *

No
Not sure
1-2 Months
3-5 Months
6 Months or more

Service-Connected Disability? *

Yes
No
Not sure

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Non-Retirement Based Supplemental Security Income (SSI)

Were you receiving Non-Retirement Based Supplemental Security Income (SSI) from the SSA prior to accepting this job? *

Yes
No
Unsure

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Criminal History

Have you ever been convicted of a felony? *

Yes
No
Unsure

Date of Conviction *

Date of Release *

Type of Conviction *

Federal Conviction
State Conviction
Not Sure

State of Conviction *

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Recent Unemployment

Have you been unemployed in the last 27 weeks? *

Yes
No
Unsure

Did you receive unemployment benefits? *

Yes
No
Unsure

State where benefits were received *

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Tribal Affiliation

Are you or your spouse a member of a Native American Tribe? *

Yes
No
Unsure

Tribe Name *

Certificate of Degree of Indian Blood # *

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Referral Source

Were you referred to this employer by any of the following? *

Vocational Rehabilitation
Ticket to Work Program
Department of Veteran Affairs
None

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Signature *

Clear Signature

Date

Save and Resume Later

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Email *

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