Uscis Form I-9 - Employment Eligibility Verification - 2016 Page 2
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3Section 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 examine a combination of one document from List B and one document from List C as listed on
the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title,
issuing authority, document number, and expiration date, if any.)
Employee Last Name, First Name and Middle Initial from Section 1:
OR
AND
List A
List B
List C
Identity and Employment Authorization
Identity
Employment Authorization
Document Title:
Document Title:
Document Title:
Issuing Authority:
Issuing Authority:
Issuing Authority:
Document Number:
Document Number:
Document Number:
Expiration Date (if any)(mm/dd/yyyy):
Expiration Date (if any)(mm/dd/yyyy):
Expiration Date (if any)(mm/dd/yyyy):
Document Title:
Issuing Authority:
Document Number:
Expiration Date (if any)(mm/dd/yyyy):
3-D Barcode
Do Not Write in This Space
Document Title:
Issuing Authority:
Document Number:
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.
(See instructions for exemptions.)
The employee's first day of employment (mm/dd/yyyy):
Date (mm/dd/yyyy)
Title of Employer or Authorized Representative
Signature of Employer or Authorized Representative
Last Name (Family Name)
First Name (Given Name)
Employer's Business or Organization Name
City or Town
Zip Code
Employer's Business or Organization Address (Street Number and Name)
State
Section 3. Reverification and Rehires
(To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable) (mm/dd/yyyy):
C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee
presented that establishes current employment authorization in the space provided below.
Document Number:
Expiration Date (if any)(mm/dd/yyyy):
Document Title:
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.
Print Name of Employer or Authorized Representative:
Signature of Employer or Authorized Representative:
Date (mm/dd/yyyy):
Form I-9 03/08/13 N
Page 8 of 9
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