Employment Eligibility Verification

USCIS Form I-9

Department of Homeland Security

U.S. Citizenship and Immigration Services

START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. EmT & Cployers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation

(Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer)

Full Name

Name *

First Name (Given Name)

Last Name *

Last Name (Family Name)

Middle Initial

Other Last Names Used (if any)

Address *

Street number and Name

Apt. Number *

Apt. Number

City or Town *

City or Town

State (Two-Letter Abbreviation) *

State (Two-Letter Abbreviation)

Zip Code *

Zip Code

Date of Birth (mm/dd/yyyy)

Date

U.S. Social Security Number *

Employee's Email Address *

[email protected]

Employee's Telephone Number

(555) 555-5555

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident (Alien Registration Number/USCIS Number)

4. An alien authorized to work until (enter the expiry date below):

Signature of Employee *

Clear

List A

Document Title 1:

Issuing Authority:

Document Number (if any):

Expiration Date (if any):

Date

Document Title 2:

Issuing Authority:

Document Number (if any):

Expiration Date (if any):

Date

Document Title 3:

Issuing Authority:

Document Number (if any):

Expiration Date (if any):

Date

List B

Document Title 1:

Issuing Authority:

Document Number (if any):

Expiration Date (if any):

Date

AND

List C

Document Title 1:

Issuing Authority:

Document Number (if any):

Expiration Date (if any):

Date

Additional information:

Check here if you used an alternative procedure authorized by DHS to examine documents *

Check here if you used an alternative procedure authorized by DHS to examine documents.

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.

First Day of Employment (mm/dd/yyyy):

Date

Last Name, First Name and Title of Employer or Authorized Representative

Title

First Name (Given Name)

First Name

Last Name (Family Name)

Last Name

Signature of Employer or Authorized Representative *

Clear

Today's Date (mm/dd/yyyy) *

Employer's Business or Organization Name

Employer's Business or Organization Address

Address (Street Number and Name)

City

City or Town

State

State (Two-Letter Abbreviation)

Zip Code