Employment Eligibility Verification
First Name (Given Name)
*
Middle Initial
Last Name (Family Name)
*
Other Last Names Used
Address (Street Number and Name)
*
Apt. Number
City or Town
*
State
*
ZIP Code
*
Date of Birth (mm/dd/yyyy)
*
-
Month
-
Day
Year
Date
U.S. Social Security Number
*
Employee's Email Address
*
Employee's Telephone Number
*
I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.
Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):
1. A citizen of the United States
2. A noncitizen national of the United States (See Instructions.)
3. A lawful permanent resident (Enter USCIS or A-Number.)
4. An alien authorized to work until
Enter USCIS or A-Number.
(exp. date, if any)
-
Month
-
Day
Year
If you check Item Number 4., enter one of these:
USCIS A-Number
Form I-94 Admission Number
Foreign Passport Number and Country of Issuance
Signature of Employee
Today's Date (mm/dd/yyyy)
-
Month
-
Day
Year
Date
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Should be Empty: