I-9 - Employment Eligibility Verification

I-9 - Employment Eligibility Verification
U.S. Citizenship and Immigration Services

OMB No. 1615-0047 Expires 10/31/2022

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.
Name*

Last NameFirst NameMiddle Name
Other Last Name(s) Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
Social Security Number*
Employee's E-mail Address
example@example.com
Employee's Telephone Number
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)

1. A citizen of the United States2. A noncitizen national of the United States (See instructions)3. A lawful permanent resident (Alien Registration Number/USCIS Number):4. An alien authorized to work
Enter Alien Registration Number/USCIS Number
Expiration date, if applicable:

MonthDayYear
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number
3. Foreign Passport Number
Country of Issuance
Signature

Clear
Date

MonthDayYear
Date
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.
Preparer and/or Translator Certification (check one) (Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1)

I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
Signature

Clear
Date

MonthDayYear
Date
Name

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

Address (Street Number and Name)

Street Address Line 2

City or TownState / Province

Postal / Zip Code
State
ZIP Code

LIST A - Documents that Establish Both Identity and Employment Authorization
1. U.S. Passport or U.S. Passport Card
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
  1. Foreign passport; and
  2. Form I-94 or Form I-94A that has the following:
    (1) The same name as the passport; 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 limitations identified on the form.
6. Passport from the Federated States
  of Micronesia (FSM) or the Republic
  of the Marshall Islands (RMI) with
  Form I-94 or Form I-94A indicating
  nonimmigrant admission under the
  Compact of Free Association Between
  the United States and the FSM or RMI
Or

List B - Documents that Establish Identity (must submit list C also if you choose this option)
1. Driver's license or ID card issued by a 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
2. ID card issued by federal, state or local government agencies or entities,
  provided it contains a photograph or information such as name, date of birth,
  gender, height, eye color, and address
3. School ID card with a photograph
4. Voter's registration card
5. U.S. Military card or draft record
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
9. Driver's license issued by a Canadian government authority.
For persons under age 18 who are unable to present a document listed above:
1. School record or report card
2. Clinic, doctor, or hospital record
3. Day-care or nursery school record
List C - Documents that Establish Employment Authorization
1. 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 INS AUTHORIZATION
  3. VALID FOR WORK ONLY WITH DHS AUTHORIZATION
2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
4. Native American tribal document
5. U.S. Citizen ID Card (Form I-197)
6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
7. Employment authorization document issued by the Department of Homeland Security
Will you be submitting ID from List A or List B and C?*

List AList B and C
Take a photo of ID (from List A)*
Take a photo of 1st ID*
Take a photo of 2nd ID*
Should be Empty: