I-9 Form

Employment Eligibility Verification
Section 1. Employee Information and Attestation

Employees must complete and sign Section of Form no later than the first day of employment, but not before accepting a job offer.
Name*

Last Name Given NameMiddle 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)*

MonthDayYear
Date
U.S. Social Security Number*
First three digits
U.S. Social Security Number*
Second two digits
U.S. Social Security Number*
Last four digits
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
3. A lawful permanent resident (Alien Registration Number/USCIS Number)
Date

MonthDayYear
Date
If you check item number 4. Enter one of these:
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number
3. Foreign Passport Number
Signature of the employee

Clear
Date

MonthDayYear
Date
Section 2: Employer Review and Verification

Employers of their authorized representative must complete and sign Section 2 within three business days after the employee's file of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the DHS, documentation from List A or a combination in the box:
Document Title 1
Issuing Authority
Document Number (if any)
Expiration Date

MonthDayYear
Date
Document Title 2 (if any)
Issuing Authority
Document Number (if any)
Expiration date

MonthDayYear
Date
Issuing Authority
Document Title (if any)
Document Number (if any)
Expiration Date (if any)

MonthDayYear
Date
Check here if you need an alternative procedure authorized by DHS to examine documents.

YesNo
Additional Information
Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears 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.
First Day of Employment

MonthDayYear
Date
Name

Last Name (Family Name)FIrst Name
Signature of Employer or Authenticated Representative

Clear
Date

MonthDayYear
Date
Employer's Business or Organization Name
Employer's Business or Organization Address

City Town

Street Address Line 2

State and ZipcodeState / Province

Postal / Zip Code

Reverification and Rehire (formerly Section 3)
Name

Last NameFirst NameMiddle Initial
Date of Rehire (if applicable)

MonthDayYear
Date
Name

Last NameFirst NameMiddle Initial
Document Title
Document Number (if any)
Expiration Date

MonthDayYear
Date
I 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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.
Name of Employer or Authorized Representative

First NameLast Name
Signature of Employer or Authorized Representative

Clear
Date

MonthDayYear
Date
Additional information (initial and date each notation)
Check if you used an alternative procedure authorized by DHS to enhance documents.

YesNo
Date Rehire

MonthDayYear
Date
Name

Last NameFirst NameMiddle Initial
Document Title
Document Number
Expiration Date

MonthDayYear
Date
I 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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.
Name of Employer or Authorized Representative

First NameLast Name
Signature of Employer or Authorized Representative

Clear
Date

MonthDayYear
Date
Additional information (initial and date each notation)
Check if you used an alternative procedure authorized by DHS to enhance documents.

YesNo
Date Rehire

MonthDayYear
Date
Name

Last NameFirst NameMiddle Initial
Document Title
Document Number
Expiration Date

MonthDayYear
Date
I 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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.
Name of Employer or Authorized Representative

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Additional information (initial and date each notation)
Check if you used an alternative procedure authorized by DHS to enhance documents.

YesNo
Should be Empty:

Employment Eligibility Verification

Section 1. Employee Information and Attestation

Section 2: Employer Review and Verification

Reverification and Rehire (formerly Section 3)