Employment Eligibility Verification

Employment Eligibility Verification
Last Name (Family Name)First Name (Given Name)Middle InitialOther Last Names (if any)
Address*

(Street Number and Name)

Apt. Number

CityState

Zip Code
Date of Birth*

MonthDayYear
U.S. Social Security Number*
SSN1
SSN2
SSN3
SSN4
SSN5
SSN6
SSN7
SSN8
SSN9
Employee's Email Address
Employee's Telephone Number
I attest, under penalty of perjury, that I am (check one of the following boxes):*

A citizen of the United StatesA noncitizen national of the United States (See instructions)A lawful permanent resident (Alien Registration Number/USCIS Number):An alien authorized to work until:
(expiration date, if applicable):

MonthDayYear
Some aliens may write "N/A" in the expiration date field (see instructions)
1. Alien Registration Number/USCIS Number (if applicable):
OR
2. Form I-94 Admission Number (if applicable):
OR
3. Foreign Passport Number (if applicable):
Country of Issuance:
Signature of Employee

Clear
Today's Date

MonthDayYear
Preparer and/or Translator Certification (check one):

I did not use a preparer or translator.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.)
I attest, under penalty of perjury, that I 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

Clear
Today's Date

MonthDayYear
Last Name (Family Name)First Name (Given Name)
Address

Address (Street Number and Name)

CityState

Zip Code