Employment Eligibility Verification

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.

It is illegal to discriminate against work-authorized individuals. Employers 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.)

Last Name (Family Name)(Required)

First Name (Given Name)(Required)

Middle Initial(Required)

Other Last Names Used (if any)

Address (Street Number and Name)(Required)

Apt. Number(Required)

City or Town(Required)

State(Required)

ZIP Code(Required)

Date of Birth (mm/dd/yyyy)(Required)

U.S. Social Security Number(Required)

Employee's E-mail Address(Required)

Employee's Telephone Number(Required)

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):(Required)

A citizen of the United States

A noncitizen national of the United States (See instructions)

A lawful permanent resident

An alien authorized to work until (See instructions)Some aliens may write "N/A" in the expiration date field.

(Alien Registration Number/USCIS Number):(Required)

Alien Registration Number/USCIS Number:/Form I-94 Admission Number:/Foreign Passport Number:(Required)

Signature of Employee(Required)

Today's Date(Required)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator(Required)

Today's Date(Required)

Last Name (Family Name)(Required)

First Name (Given Name)(Required)

Address (Street Number and Name)(Required)

City or Town(Required)

State(Required)

ZIP Code(Required)

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Employee Info from Section 1

Last Name (Family Name)(Required)

First Name (Given Name)(Required)

M.I.(Required)

Citizenship/Immigration Status(Required)

List A Identity and Employment Authorization

List B Identity

List C Employment Authorization

Document Title(Required)

Issuing Authority(Required)

Document Number(Required)

Expiration Date (if any) (mm/dd/yyyy)

Document Title(Required)

Additional Information

Issuing Authority(Required)

Document Number(Required)

Expiration Date (if any) (mm/dd/yyyy)(Required)

Document Title(Required)

Issuing Authority(Required)

Document Number(Required)

Expiration Date (if any) (mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear 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.

The employee's first day of employment (mm/dd/yyyy):(Required)

Signature of Employer or Authorized Representative(Required)

Date(Required)

Title of Employer or Authorized Representative(Required)

Last Name of Employer or Authorized Representative(Required)

First Name of Employer or Authorized Representative(Required)

Employer's Business or Organization Name(Required)

Employer's Business or Organization Address (Street Number and Name)(Required)

City or Town(Required)

State(Required)

Zip Code(Required)

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)

A. New Name (if applicable)

B. Date of Rehire (if applicable)

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

Document Title(Required)

Document Number(Required)

Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative

Today's Date

Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

1. U.S. Passport or U.S. Passport Card

2. Permanent Resident Card or Alien

Registration Receipt Card (Form I-551)

3. Foreign passport that contains a

temporary I-551 stamp or temporary

I-551 printed notation on a machine-

readable immigrant visa

4. Employment Authorization Document

that contains a photograph (Form

I-766)

5. For a nonimmigrant alien authorized

to work for a specific employer

because of his or her status:

Documents that Establish

Both Identity and

Employment Authorization

6. Passport from the Federated States

of Micronesia (FSM) or the Republic

of the Marshall Islands (RMI) with

Form I-94 or Form I-94A indicating

nonimmigrant admission under the

Compact of Free Association Between

the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has

the following:

(1) The same name as the passport;

and

(2) An endorsement of the alien's

nonimmigrant status as long as

that period of endorsement has

not yet expired and the

proposed employment is not in

conflict with any restrictions or

limitations identified on the form.

LIST B

Documents that Establish

Identity

1. Driver's license or ID card issued by a

State or outlying possession of the

United States provided it contains a

photograph or information such as

name, date of birth, gender, height, eye

color, and address

2. ID card issued by federal, state or local

government agencies or entities,

provided it contains a photograph or

information such as name, date of birth,

gender, height, eye color, and address

3. School ID card with a photograph

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish

Identity

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner

Card

8. Native American tribal document

For persons under age 18 who are

unable to present a document

listed above:

9. Driver's license issued by a Canadian

government authority

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

LIST C

Documents that Establish

Employment Authorization

1. A Social Security Account Number

card, unless the card includes one of

the following restrictions:

2. Certification of report of birth issued

by the Department of State (Forms

DS-1350, FS-545, FS-240)

(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

3. Original or certified copy of birth

certificate issued by a State,

county, municipal authority, or

territory of the United States

bearing an official seal

4. Native American tribal document

5. U.S. Citizen ID Card (Form I-197)

6. Identification Card for Use of

Resident Citizen in the United

States (Form I-179)

Documents that Establish

Employment Authorization

7. Employment authorization

document issued by the

Department of Homeland Security

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

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