Form I-9 - Employment Eligibility Verfication Page 2
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3U.S. Department of Justice
OMB No. 1115-0136
Employment Eligibility Verfication
Immigration and Naturalization Service
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 of 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 am aware that federal law provides for
I attest, under penalty of perjury, that I am (check one of the following).
o
imprisonment and/or fines for false statements
A citizen or national of the United States
o
or use of false documents in connection with
A Lawful Permanent Resident (Alien # A_______________________________
o
the completion of this form.
An alien authorized to work until ____________/____________/____________
(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)
O R
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 age
ncies may
omit the date the employee began employment).
Signature of Employer or Authorized Representative
Print Name
Title
HP Representative Phone #
Date (month/day/year)
Business or Organization Name
Address (Street Name and Number, City, State, Zip Codee)
Hewlett-Packard Company USESC
1266 Kifer Road, Sunnyvale, CA 94086
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 establish
es current
employment eligibility.
Document Title: __________________ Document #: ___________________
Expiration Date (if any): ____/____/____
I attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, an
d if the employee
presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Date (month/day/year)
Signature of Employer or Authorized Representative
Form I-9 (Rev. 11-21-91) N
N05030
9/94
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