Uscis Form I-9 - Employment Eligibility Verification - 2016

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Employment Eligibility Verification
Form I-9
Department of Homeland Security
OMB No. 1615-0047
U.S. Citizenship and Immigration Services
Expires 03/31/2016
Read instructions carefully before completing this form. The instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) they will accept from an employee. The refusal to hire 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)
First Name (Given Name)
Middle Initial
Other Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
Zip Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
E-mail Address
Telephone Number
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):
A citizen of the United States
A noncitizen national of the United States (See instructions)
A lawful permanent resident (Alien Registration Number/USCIS Number):
An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy)
. Some aliens may write "N/A" in this field.
(See instructions)
For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number:
1. Alien Registration Number/USCIS Number:
3-D Barcode
Do Not Write in This Space
2. Form I-94 Admission Number:
If you obtained your admission number from CBP in connection with your arrival in the United
States, include the following:
Foreign Passport Number:
Country of Issuance:
Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)
Signature of Employee:
Date (mm/dd/yyyy):
Preparer and/or Translator Certification
(To be completed and signed if Section 1 is prepared by a person other than the
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the
information is true and correct.
Signature of Preparer or Translator:
Date (mm/dd/yyyy):
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
Zip Code
Employer Completes Next Page
Form I-9 03/08/13 N
Page 7 of 9


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