Employment Eligibility Verification
USCIS
Department of Homeland Security
Form I-9
Signature
*
U.S. Citizenship and Immigration Services OMB No. 1615-0047 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.
Name
*
First Name
Last Name
Middle Initial
*
Other Last Names Used (if any)
Address
*
Street Address
Street Address Line 2
City
State (Abbreviation)
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Date
U.S. 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):
Select One of the Following:
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work
Lawful Permanent Resident Number:
Alien Registration Number / USCIS Number:
Alien Authorized to Work Until Date:
-
Month
-
Day
Year
Date (if applicable)
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:
OR
2. Form I 94 Admission Number:
OR
3. Foreign Passport Number:
OR
Country of Issuance:
Signature of Employee
*
Date
-
Month
-
Day
Year
Date
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 1I 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
Today's Date
/
Month
/
Day
Year
Date
Name of Preparer
First Name (Given Name)
Last Name (Family Name)
Address (Street Number and Name)
Address
Street Address (Street Number and Name)
Street Address Line 2
City
State (Abbreviation)
Postal / Zip Code
Employment Eligibility Verification
USCIS
Department of Homeland Security
Form I-9
Employee Info from Section 1
Name
First Name (Given Name)
Last Name (Family Name)
Middle Initial
Citizenship/Immigration Status
Citizen / Authorized Alien
Verification Documents
Submit a valid copy of documents listed below: Either a Valid Passport or BOTH a Valid Drivers License and a Valid Social Security Card.
Valid Passport
*
Browse Files
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of
Valid Driver's License
*
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of
Valid Social Security Card
*
Browse Files
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of
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Employee Illness Reporting Agreement
You play an important role in providing safe food to the general public. As a food handler, you have a responsibility to report the symptoms and conditions listed below.
I agree to report to the person in charge any of the following symptoms of foodborne illness: 1. Vomiting 2. Diarrhea 3. Jaundice – yellow skin or eye color 4. Sore throat with fever 5. Infected wounds I agree to report to the person in charge if a doctor says that I have one of the following infections: 1. E.coli 2.Salmonella Typhi 3.Non-Typhoidal Samonella 4. Shigella 5. Hepatitis A 6. Norovirus I agree to report to the person in charge if I am exposed to foodborne illness in any of the following ways: 1. I am exposed to a confirmed outbreak of foodborne illness; 2. Someone who lives in my house is diagnosed with a foodborne illness; 3. Someone who lives in my house attends an event or works in a place which has aconfirmed outbreak of foodborne illness.
Employee Acknowledgement
I understand that if I fail to meet the terms of this agreement, action could be taken by the food establishment or by the County Health Department that may affect my employment.
Employee Name
*
First Name
Last Name
Signature
*
Date
-
Month
-
Day
Year
Date
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