Employment Eligibility Verification

Employment Eligibility Verification

Complete the employee and employer sections based on the referenced PDF structure. This is a standard online form, not a Smart PDF.
Employee Information
Last Name (Family Name)
First Name (Given Name)
Middle Initial (if any)
Other Last Names Used (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
U.S. Social Security Number
Employee's Email Address
example@example.com
Employee's Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Citizenship / Immigration Status
Citizenship or Immigration Status
Alien Registration Number/USCIS Number (for lawful permanent resident)
Expiration Date (mm/dd/yyyy)

MonthDayYear
Date
Alien Registration Number/USCIS Number (for alien authorized to work)
Form I-94 Admission Number
Foreign Passport Number
Country of Issuance (Foreign Passport)
Upload State ID, Drivers License, Birth Certificate, or Passport

Cancelof
Upload Social Security

Cancelof
Employee Attestation

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.
Signature of Employee
Today's Date

MonthDayYear
Date
Employee STOP (only complete above to employee signature)
Section 2: Employer Review and Verification:

Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see instructions.
Used alternative procedure authorized by DHS to examine documents
List A - Document Title 1
List A - Issuing Authority 1
List A - Document Number 1
List A - Expiration Date 1

MonthDayYear
Date
List A - Document Title 2
List A - Issuing Authority 2
List A - Document Number 2
List A - Expiration Date 2

MonthDayYear
Date
List A - Document Title 3
List A - Issuing Authority 3
List A - Document Number 3
List A - Expiration Date 3

MonthDayYear
Date
List B - Document Title
List B - Issuing Authority
List B - Document Number
List B - Expiration Date

MonthDayYear
Date
List C - Document Title
List C - Issuing Authority
List C - Document Number
List C - Expiration Date

MonthDayYear
Date
Additional Information (Section 2)
Employer Information and Signature
Last Name
First Name and Title
Signature of Employer or Authorized Representative
Today's Date

MonthDayYear
Date
Employer's Business or Organization Name
Employer's Business or Organization Address, City or Town, State, ZIP Code

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Should be Empty:

Employment Eligibility Verification

Employee Information

Citizenship / Immigration Status

Employee Attestation

Employee STOP (only complete above to employee signature)

Section 2: Employer Review and Verification:

Employer Information and Signature