Employment Eligibility Verification

Employment Eligibility Verification

Form I-9 OMB No. 1115-0136
U.S. Department of Justice

Immigration and Naturalization Service

Read First
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 Verification

To be completed and signed by employee at the time employment begins.
Name

First Name (Given Name)Middle InitialLast Name (family name)
Other Names Used
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Social SN#
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
I 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.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Alien # or Admission #
Alien# A
Authorized to work until

MonthDayYear
Date
Employee's Signature
Date (mm/dd/yyyy)

MonthDayYear
Date
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

MonthDayYear
Date

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
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)

MonthDayYear
Date
Document Number
Expiration Date (if any) (mm/dd/yyyy)

MonthDayYear
Date
List B
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)

MonthDayYear
Date
List C
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)

MonthDayYear
Date
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.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)

MonthDayYear
Date
Name

First Name of Employer or Authorized RepLast Name of Employer or Authorized Representative
Title of Employer or auth Representative
Employer's Business or Organization Name
Address

Employer's Business or Organization Address (Street Number and Name)

Street Address Line 2

City or TownState

ZIP Code
Section 3. Updating and Reverification.

To be completed and signed by employer.
A New Name (if applicable)

First Name (Given Name)Middle InitialLast Name (Family Name)
B. Date of Rehire (if applicable)

MonthDayYear
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)

MonthDayYear
Date
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
Date (mm/dd/yyyy)

MonthDayYear
Date
LISTS OF ACCEPTABLE DOCUMENTS
ssnCalc
Should be Empty:

Employment Eligibility Verification

U.S. Department of Justice

Read First

Section 1. Employee Information and Verification

Preparer and/or Translator Certification.

Section 2. Employer Review and Verification

List A

List B

List C

Section 3. Updating and Reverification.

LISTS OF ACCEPTABLE DOCUMENTS