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- 1. USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services Form I-9 10/21/2019 Page 1 of 3 ?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 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Middle 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) - - Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident 4. An alien authorized to work until (See instructions) (expiration date, if applicable, mm/dd/yyyy): (Alien Registration Number/USCIS Number): Some aliens may write "N/A" in the expiration date field. 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): Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. 1. Alien Registration Number/USCIS Number: 2. Form I-94 Admission Number: 3. Foreign Passport Number: Country of Issuance: OR OR QR Code - Section 1 Do Not Write In This Space Signature of Employee Today's Date (mm/dd/yyyy) Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1. (Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.) I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator Today's Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town State ZIP Code Employer Completes Next Page
- 2. Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services 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.") Last Name (Family Name) M.I. First Name (Given Name) Employee Info from Section 1 Citizenship/Immigration Status List A Identity and Employment Authorization Identity Employment Authorization OR List B AND List C Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space Document Title Issuing Authority Document Number Expiration Date (if any) (mm/dd/yyyy) Document Title Issuing Authority Document Number Expiration Date (if any) (mm/dd/yyyy) Document Title Issuing Authority Document Number Expiration Date (if any) (mm/dd/yyyy) Document Title Issuing Authority Document Number Expiration Date (if any) (mm/dd/yyyy) Document Title Issuing Authority Document Number Expiration Date (if any) (mm/dd/yyyy) 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) Today's Date (mm/dd/yyyy) Signature of Employer or Authorized Representative Title of Employer or Authorized Representative Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial B. Date of Rehire (if applicable) Date (mm/dd/yyyy) Document Title Document Number Expiration Date (if any) (mm/dd/yyyy) 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. 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 document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
- 3. LISTS OF ACCEPTABLE DOCUMENTS 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. LIST A 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 1. U.S. Passport or U.S. Passport Card 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. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: Documents that Establish Both Identity and Employment Authorization 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 b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. a. Foreign passport; and For persons under age 18 who are unable to present a document listed above: 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, gender, height, eye color, and address 9. Driver's license issued by a Canadian government authority 3. School ID card with a photograph 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record 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, gender, height, eye color, and address 4. Voter's registration card 5. U.S. Military card or draft record Documents that Establish Identity LIST B OR AND LIST C 7. Employment authorization document issued by the Department of Homeland Security 1. A Social Security Account Number card, unless the card includes one of the following restrictions: 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 6. Identification Card for Use of Resident Citizen in the United States (Form I-179) Documents that Establish Employment Authorization 5. U.S. Citizen ID Card (Form I-197) (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION (1) NOT VALID FOR EMPLOYMENT Page 3 of 3 Form I-9 10/21/2019 Examples of many of these documents appear in the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts.