Employment Eligibility Verification printable pdf download

Employment Eligibility Verification

(Form I-9)

EMPLOYEE INFORMATION AND VERIFICATION: (To be completed and signed by employee.)

Name: (Print or Type) Last

First

Middle

Birth Name

Address: Street Name and Number

City

State

ZIP Code

Date of Birth (Month/Day/Year)

Social Security Number

I attest, under penalty of perjury, that I am (check a box):

1. A citizen or national of the United States.

2. An alien lawfully admitted for permanent residence (Alien Number A _______________________).

3. An alien authorized by the Immigration and Naturalization Service to work in the United States (Alien Number A ___________________________,

or Admission Number ____________________, expiration of employment authorization, if any ________________________).

I attest, under penalty of perjury, the documents that I have presented as evidence of identity and employment eligibility are genuine and relate to me. I am

aware that federal law provides for imprisonment and/or fine for any false statements or use of false documents in connection with this certificate.

Signature

Date (Month/Day/Year)

PREPARER/TRANSLATOR CERTIFICATION (To be completed if prepared by person other than the employee.) I attest, under penalty of

perjury, that the above was prepared by me at the request of the named individual and is based on all information of which I have any knowledge.

Signature

Name (Print or Type)

Address (Street Name and Number)

City

State

Zip Code

2 EMPLOYER REVIEW AND VERIFICATION:

(To be completed and signed by employer.)

Instructions:

Examine one document from List A and check the appropriate box, OR examine one document from List B and one from List C and check the appropriate boxes.

Provide the Document Identification Number and Expiration Date for the document checked.

List A

List B

List C

Documents that Establish

and

Identity and Employment Eligibility

Identity

Employment Eligibility

___________________________________

1. Original Social Security Number Card

1. A State-issued driver's license or a State-

(other than a card stating it is not valid

issued I.D. card with a photograph, or

1. United States Passport.

for employment)

information, including name, sex, date of

birth, height, weight, and color of eyes.

2. Certificate of United States Citizenship

2. A birth certificate issued by State,

county, or municipal authority bearing a

2. U.S. Military Card

3. Certificate of Naturalization

seal or other certification.

4. Unexpired foreign passport with

3. Unexpired INS Employment

3. Other (Specity document and issuing

attached Employment Authorization

Authorization (Specify form)

authority)

5. Alien Registration Card with photograph

#____________________________________

Document Identification

#____________________________________

Expiration Date (if any)

_____________________________________

CERTIFICATION: I attest, under penalty of perjury, that I have examined the documents presented by the above individual, that they appear to be genuine

and to relate to the individual named, and that the individual, to the best of my knowledge, is eligible to work in the United States.

Signature

Name (Print or Type)

Title

Employer Name

Address

Date

Form I-9 (05/07/87)

U.S. Department of Justice

OMB No. 1115-0136

Immigration and Naturalization Service

Form 1012, Printed by: