New Employee Work Authorization Questionnaire Form
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1NEW EMPLOYEE WORK AUTHORIZATION QUESTIONNAIRE
Name: ___________________________________
SS#/TIN: _________________
Are you a U.S. Citizen?
YES _______
NO _______
Are you a permanent resident alien? YES _______
NO _______
If you answered NO to both of the above, then please provide the following information:
U.S. LOCAL STREET ADDRESS:
FOREIGN RESIDENCE ADDRESS:
___________________________________________
_____________________________________________
Address Line 2:______________________________
Address Line 2:_______________________________
Address Line 3:______________________________
Address Line 3/City:___________________________
City:_______________________________________
Postal Code:________Province/Region____________
State:________________________Zip:__________
Foreign Country:_________________
Country of Citizenship:_______________________
Country that Issued Passport:____________________
Passport #:_________________________________
____________
COUNTRY OF TAX RESIDENCE IF DIFFERENT FROM FOREIGN RESIDENCE ADDRESS:
Did tax residency end? __Yes __ No If yes, when_____/____/_____ (Month/Day/Year)
IMMIGRATION STATUS*** (CHECK ONE):
___ J-1 Exchange Visitor
____ H-1 Temporary Employee
___ F-1 Student
____ Other:_______________________________
IF IMMIGRATION STATUS IS J-1, WHAT IS THE SUBTYPE? (CHECK ONE):
____ Student
____ Professor
____ Research Scholar
____ Short Term Scholar
____ Other:________________________________
WHAT IS THE ACTUAL PRIMARY ACTIVITY OF THE VISIT? (CHECK ONE):
____ Studying in a Degree Program
____Observing
____ Conducting Research
____ Studying in a Non-Degree Program
____ Training
____ Consulting
____ Teaching
____ Lecturing
____ Other:______________________
WHAT IS THE ACTUAL DATE YOU
WHAT IS THE START DATE OF
WHAT IS THE PROJECTED END
ENTERED THE UNITED STATES?
YOUR IMMIGRATION STATUS
DATE OF YOUR IMMIGRATION
(FIRST TIME THIS VISIT)
FOR THIS PRIMARY ACTIVITY?
STATUS PRIMARY ACTIVITY?
______ /_____/_____
______/_____/______
_______/____/_____
Month Day Year
Month Day Year
Month Day Year
Were you present in the United States 31 days during the current year? ___Yes ___No
If, yes, how many days? ______
How many days were you in the United States in the first year preceding the current year? _____ days
How many days were you in the United States in the second year preceding the current year? _____ days
I certify that the above information is true and correct.
_______________________________________________
___________________
Signature
Date
***Please provide copies of relevant immigration documents (e.g. Forms I-94, IAP-66, and/or I-20).
Payroll Use Only
Year
X 1+
X 1/3 +
X 1/6 +
=
Total Days
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