Instructions For Uscis Form I-9 - Employment Eligibility Verification Page 17
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18USCIS
Employment Eligibility Verification
Form I-9
Department of Homeland Security
OMB No. 1615-0047
U.S. Citizenship and Immigration Services
Expires 08/31/2019
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.")
Last Name (Family Name)
First Name (Given Name)
M.I.
Citizenship/Immigration Status
Employee Info from Section 1
List A
OR
List B
AND
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
QR Code - Sections 2 & 3
Additional Information
Issuing Authority
Do Not Write In This Space
Document Number
Expiration Date (if any)(mm/dd/yyyy)
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.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
State
City or Town
ZIP Code
Employer's Business or Organization Address (Street Number and Name)
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
Document Number
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 (mm/dd/yyyy)
Name of Employer or Authorized Representative
Page 2 of 3
Form I-9 07/17/17 N
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