Employment Eligibility Verification USCIS

Department of Homeland Security Form -9

a, . » ‘ % OMB No. 1615-0047
U.S. Citizenship and Immigration Services Expires 08/31/2019

> START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ
an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number | City or Town State ZIP Code
Date of Birth (mm/dd/yyyy) | U.S. Social Security Number _| Employee's E-mail Address Employee's Telephone Number

| am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.

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

(1 1. Acitizen of the United States

(2 2. Anoneitizen national of the United States (See instructions)

Oo 3. A lawful permanent resident (Alien Registration Number/USCIS Number):

[1 4.Analien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: aes eee
An Alien Registration Number/USCIS Number OR Form !-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:
OR

2. Form I-94 Admission Number:

OR
3. Foreign Passport Number:

Country of Issuance:

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one):
OO I did not use a preparer or translator. oO A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

l attest, under penalty of perjury, that | have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.

Signature of Preparer or Translator Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town State ZIP Code

E107] Employer Completes Next Page oS

Form I-9 07/17/17 N Page | of 3



Employment Eligibility Verification USCIS

Department of Homeland Security Form I-9

as i Fines : OMB No. 1615-0047
USS. 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
lof Acceptable Documents. ")

Eiplovae Into WO eottion’t Last Name (Family Name) First Name (Given Name) M1. | Citizenship/immigration Status
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
Issuing Authority Additional Information Do nivaie hme aes
Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Certification: | attest, under penalty of perjury, that (1) | 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

Employer's Business or Organization Address (Street Number and Name) _| City or Town State ZIP Code

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/yy)

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/yy)

\ 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) | 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

Form I-9 07/17/17 N Page 2 of 3


LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED

Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.

LISTA

Documents that Establish
Both Identity and
Employment Authorization

LISTB LIsTC
Documents that Establish Documents that Establish
Identity Employment Authorization

AND

1. U.S. Passport or U.S. Passport Card

2. Permanent Resident Card or Alien
Registration Receipt Card (Form |-551)

3. Foreign passport that contains a
temporary |-551 stamp or temporary
1-551 printed notation on a machine-
readable immigrant visa

1. Driver's license or ID card issued by a fi
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address

A Social Security Account Number
card, unless the card includes one of
the following restrictions:

(1) NOT VALID FOR EMPLOYMENT
(2) VALID FOR WORK ONLY WITH

4. Employment Authorization Document
that contains a photograph (Form
1-766)

INS AUTHORIZATION
2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH
government agencies or entities, DHS AUTHORIZATION

provided it contains a photograph or
information such as name, date of birth,] 2.
gender, height, eye color, and address

Certification of report of birth issued
by the Department of State (Forms

5. Fora nonimmigrant alien authorized
to work for a specific employer
because of his or her status:

a. Foreign passport; and

b. Form |-94 or Form I-94A that has
the following:

and

(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or

DS-1350, FS-545, FS-240)

(1) The same name as the passport;

3. School ID card with a photograph a - 5
3. Original or certified copy of birth
4. Voter's registration card certificate issued by a State,
rs county, municipal authority, or

5. U.S. Military card or draft record territory of the United States
6. Military dependent's ID card bearing an official seal
7. U.S. Coast Guard Merchant Mariner 4. Native American tribal document

Cag 5. U.S. Citizen ID Card (Form I-197)
8. Native American tribal document

6. Identification Card for Use of

Resident Citizen in the United
States (Form |-179)

9. Driver's license issued by a Canadian
government authority

limitations identified on the form.

6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (RMI) with Form
1-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI

Employment authorization
document issued by the
Department of Homeland Security

For persons under age 18 who are | 7-
unable to present a document
listed above:

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form 1-9 07/17/17 N Page 3 of 3