Employment Verification

As required by federal law and internal policy, all new employees must verify their identity and employment authorization.
Please complete the form below and upload copies of the necessary identification documents.
If you have questions about acceptable forms of ID or how to complete this form, please contact Office Management.

Full Legal Name

First NameMiddle NameLast Name

Do you go by any other name?

First NameMiddle NameLast Name

Date of Birth

Date

Social Security Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Immigration Status

Please upload legible copies of acceptable documents.For most employees, this includes either one document from List A, or one from List B and one from List C.

List A Documents (Only Need 1)

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. Foreign passport with Form I-94 or Form I-94A with Arrival-Departure Record, and containing an endorsement to work
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

List B Documents (Also need List C Document)

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, sex, 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, sex, 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

List C Documents (Also need List B Document)

1. U.S. Social Security Card
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 (DHS)

Do you have a List A document as described above?

List A Document

List B Document

Refer to above for qualifying documents

List C Documents

Refer to above for qualifying documents

Signature