Form I-9 - Employment Eligibility Verification - Department Of Homeland Security (Page 2 of 3) in pdf

OMB No. 1615-0047; Expires 06/30/08

Form I-9, Employment

Department of Homeland Security

Eligibility Verification

U.S. Citizenship and Immigration Services

Please 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 eligible individuals. Employers CANNOT

specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a

future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins.

Print Name: Last

First

Middle Initial

Maiden Name

Address (Street Name and Number)

Apt. #

Date of Birth (month/day/year)

City

State

Zip Code

Social Security #

I attest, under penalty of perjury, that I am (check one of the following):

I am aware that federal law provides for

A citizen or national of the United States

imprisonment and/or fines for false statements or

A lawful permanent resident (Alien #) A

use of false documents in connection with the

An alien authorized to work until

completion of this form.

(Alien # or Admission #)

Employee's Signature

Date (month/day/year)

Preparer and/or Translator Certification.

(To be completed and signed if Section 1 is prepared by a person other than the employee.) 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.

Preparer's/Translator's Signature

Print Name

Address (Street Name and Number, City, State, Zip Code)

Date (month/day/year)

Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR

examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and

expiration date, if any, of the document(s).

List A

List B

AND

List C

Document title:

Issuing authority:

Document #:

Expiration Date (if any):

Document #:

Expiration Date (if any):

CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that

the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on

(month/day/year)

and that to the best of my knowledge the employee is eligible to work in the United States. (State

employment agencies may omit the date the employee began employment.)

Signature of Employer or Authorized Representative

Print Name

Title

Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)

Date (month/day/year)

Section 3. Updating and Reverification. To be completed and signed by employer.

A. New Name (if applicable)

B. Date of Rehire (month/day/year) (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility.

Document Title:

Document #:

Expiration Date (if any):

l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented

document(s), the document(s) l have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative

Date (month/day/year)

Form I-9 (Rev. 06/05/07) N