zz I9 Employment Eligibility Verification (pvtND)

Employment Eligibility Verification

Form I-9 OMB No. 1615-0047 Expires 10/31/2022
USCIS - Department of Homeland Security

U.S. Citizenship and Immigration Services
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 2. Employer or Authorized representative Review and Verification Only
Department of Homeland Security
Form I-9
U.S. Citizenship and Immigration Services

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

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Employee Info from Section 1
Name

First Name (Given Name)Last Name (Family Name)
M.I.
Citizenship/Immigration Status
List A Identity and Employment Authorization
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)

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

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

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

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

MonthDayYear
Date
Additional Information
QR Code - Sections 2 & 3 Do Not Write In This Space
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.
The employee's first day of employment (mm/dd/yyyy) (See instructions for exemptions):
Signature

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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. Reverification and Rehires (To be completed and signed by employer or authorized representative)
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
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.
Signature

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Today's Date (mm/dd/yyyy)

MonthDayYear
Date
Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTS (FYI)
All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
Refer to the instructions for more information about acceptable receipts.
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Employment Eligibility Verification

USCIS - Department of Homeland Security

Read First

Section 1. Employee Information and Attestation

Preparer and/or Translator Certification:

Department of Homeland Security

Form I-9

Employee Info from Section 1

List A Identity and Employment Authorization

List B Identity

AND

List C Employment Authorization

Refer to the instructions for more information about acceptable receipts.