Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9 OMB No.1615-0047

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

Last Name (Family Name)

First Name (Given Name)

Middle Initial (if any)

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number (if any)

City or Town

State

Zip Code

Date of Birth

U.S. Social Security Number

Employee's Email Address

Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

A citizen of the United States A noncitizen national of the United States (See Instructions.) A lawful permanent resident (Enter USCIS or A-Number.) A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:

USCIS A-Number

Form I-94 Admission Number

Foreign Passport Number and Country of Issuance

Signature of Employee

Today's Date (mm/dd/yyyy)

Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions.

Document Title 1

Issuing Authority (List A)

Issuing Authority (List B)

Issuing Authority (List C)

Document Number (if any) (List A)

Document Number (if any) (List B)

Document Number (if any) (List C)

Expiration Date (if any) (List A)

Expiration Date (if any) (List B)

Expiration Date (if any) (List C)

Document Title 2

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 3

Issuing Authority

Document Number (if any)

Expiration Date (if any)

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

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

Signature of Employer or Authorized Representative

Today's Date

Employer's Business or Organization Name

Employer's Business or Organization Address, City or Town, State, ZIP Code