Uscis Form I-9 Employment Eligibility Verification - Department Of Homeland Security

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USCIS
Employment Eligibility Verification
Form I-9
Department of Homeland Security
OMB No. 1615-0047
U.S. Citizenship and Immigration Services
Expires 08/31/2019
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. 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)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
State
Address (Street Number and Name)
Apt. Number
City or Town
ZIP Code
Date of Birth (mm/dd/yyyy)
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security 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 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):
(expiration date, if applicable, mm/dd/yyyy):
4. An alien authorized to work
until
Some aliens may write "N/A" in the expiration date field.
(See instructions)
QR Code - Section 1
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
Do Not Write In This Space
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
OR
2. Form I-94 Admission Number:
OR
3. Foreign Passport Number:
Country of Issuance:
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator.
A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
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
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
State
City or Town
ZIP Code
Address (Street Number and Name)
Employer Completes Next Page
Form I-9 11/14/2016 N
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ISA

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