Anti-Discriminationnotice

►STARTHERE:Readinstructionscarefullybeforecompletingthisform.Theinstructionsmustbeavailable,eitherinpaperorelectronically,duringcompletionofthisform.Employersareliableforerrorsinthecompletionofthisform.

ANTI-DISCRIMINATIONNOTICE:Itisillegaltodiscriminateagainstwork-authorizedindividuals.EmployersCANNOTspecifywhichdocument(s)anemployeemaypresenttoestablishemploymentauthorizationandidentity.Therefusaltohireorcontinuetoemployanindividualbecausethedocumentationpresentedhasafutureexpirationdatemayalsoconstituteillegaldiscrimination.

Section1.EmployeeInformationandAttestation(EmployeesmustcompleteandsignSection1ofFormI-9nolaterthanthefirstdayofemployment,butnotbeforeacceptingajoboffer.)
LastName(FamilyName) / FirstName(GivenName) / MiddleInitial / OtherLastNamesUsed(ifany)
Address(StreetNumberandName) / Apt.Number / CityorTown / State / ZIPCode
DateofBirth(mm/dd/yyyy) / U.S.SocialSecurityNumber / Employee'sE-mailAddress / Employee'sTelephoneNumber
- / -

Iamawarethatfederallawprovidesforimprisonmentand/orfinesforfalsestatementsoruseoffalsedocumentsinconnectionwiththecompletionofthisform.

Iattest,underpenaltyofperjury,thatIam(checkoneofthefollowingboxes):

1.AcitizenoftheUnitedStates

2.AnoncitizennationaloftheUnitedStates(Seeinstructions)

3.Alawfulpermanentresident

(AlienRegistrationNumber/USCISNumber):

4.Analienauthorizedtowork until(expirationdate,ifapplicable,mm/dd/yyyy):Somealiensmaywrite"N/A"intheexpirationdatefield.(Seeinstructions)

AliensauthorizedtoworkmustprovideonlyoneofthefollowingdocumentnumberstocompleteFormI-9:

AnAlienRegistrationNumber/USCISNumberORFormI-94AdmissionNumberORForeignPassportNumber.

QRCode-Section1

DoNotWriteInThisSpace

1.AlienRegistrationNumber/USCISNumber:

2.FormI-94AdmissionNumber:

3.ForeignPassportNumber:

CountryofIssuance:

SignatureofEmployeeToday'sDate(mm/dd/yyyy)

Preparerand/orTranslatorCertification(checkone):

Ididnotuseapreparerortranslator.Apreparer(s)and/ortranslator(s)assistedtheemployeeincompletingSection1.

(Fieldsbelowmustbecompletedandsignedwhenpreparersand/ortranslatorsassistanemployeeincompletingSection1.)

Iattest,underpenaltyofperjury,thatIhaveassistedinthecompletionofSection1ofthisformandthattothebestofmyknowledgetheinformationistrueandcorrect.

SignatureofPreparerorTranslator / Today'sDate(mm/dd/yyyy)
LastName(FamilyName) / FirstName(GivenName)
Address(StreetNumberandName) / CityorTown / State / ZIPCode

EmployerCompletesNextPage

Section2.EmployerorAuthorizedRepresentativeReviewandVerification
(EmployersortheirauthorizedrepresentativemustcompleteandsignSection2within3businessdaysoftheemployee'sfirstdayofemployment.YoumustphysicallyexamineonedocumentfromListAORacombinationofonedocumentfromListBandonedocumentfromListCaslistedonthe"ListsofAcceptableDocuments.")
EmployeeInfofromSection1 / LastName(FamilyName) / FirstName(GivenName) / M.I. / Citizenship/ImmigrationStatus

ListA

ORListBANDListC

IdentityandEmploymentAuthorizationIdentityEmploymentAuthorization

DocumentTitle / DocumentTitle / DocumentTitle
IssuingAuthority / IssuingAuthority / IssuingAuthority
DocumentNumber / DocumentNumber / DocumentNumber
ExpirationDate(ifany)(mm/dd/yyyy) / ExpirationDate(ifany)(mm/dd/yyyy) / ExpirationDate(ifany)(mm/dd/yyyy)
DocumentTitle / AdditionalInformationQRCode-Sections23
DoNotWriteInThisSpace
IssuingAuthority
DocumentNumber
ExpirationDate(ifany)(mm/dd/yyyy)
DocumentTitle
IssuingAuthority
DocumentNumber
ExpirationDate(ifany)(mm/dd/yyyy)

Certification:Iattest,underpenaltyofperjury,that(1)Ihaveexaminedthedocument(s)presentedbytheabove-namedemployee,(2)theabove-listeddocument(s)appeartobegenuineandtorelatetotheemployeenamed,and(3)tothebestofmyknowledgetheemployeeisauthorizedtoworkintheUnitedStates.

Theemployee'sfirstdayofemployment(mm/dd/yyyy): (Seeinstructionsforexemptions)

SignatureofEmployerorAuthorizedRepresentative / Today'sDate(mm/dd/yyyy) / TitleofEmployerorAuthorizedRepresentative
LastNameofEmployerorAuthorizedRepresentative / FirstNameofEmployerorAuthorizedRepresentative / Employer'sBusinessorOrganizationName
Employer'sBusinessorOrganizationAddress(StreetNumberandName) / CityorTown / State / ZIPCode
Section3.ReverificationandRehires(Tobecompletedandsignedbyemployerorauthorizedrepresentative.)
A.NewName(ifapplicable) / B.DateofRehire(ifapplicable)
LastName(FamilyName) / FirstName(GivenName) / MiddleInitial / Date(mm/dd/yyyy)
C.Iftheemployee'spreviousgrantofemploymentauthorizationhasexpired,providetheinformationforthedocumentorreceiptthatestablishescontinuingemploymentauthorizationinthespaceprovidedbelow.
DocumentTitle / DocumentNumber / ExpirationDate(ifany)(mm/dd/yyyy)

Iattest,underpenaltyofperjury,thattothebestofmyknowledge,thisemployeeisauthorizedtoworkintheUnitedStates,andiftheemployeepresenteddocument(s),thedocument(s)Ihaveexaminedappeartobegenuineandtorelatetotheindividual.

SignatureofEmployerorAuthorizedRepresentativeToday'sDate(mm/dd/yyyy)NameofEmployerorAuthorizedRepresentative

LISTSOFACCEPTABLEDOCUMENTSAlldocumentsmustbeUNEXPIRED

EmployeesmaypresentoneselectionfromListA

oracombinationofoneselectionfromListBandoneselectionfromListC.

LISTADocumentsthatEstablish
BothIdentityand
EmploymentAuthorizationO / R / LISTBLISTC
DocumentsthatEstablishDocumentsthatEstablish
IdentityEmploymentAuthorization
AND
1. U.S.PassportorU.S.PassportCard / 1. Driver'slicenseorIDcardissuedbyaStateoroutlyingpossessionoftheUnitedStatesprovideditcontainsaphotographorinformationsuchasname,dateofbirth,gender,height,eyecolor,andaddress / 1. ASocialSecurityAccountNumbercard,unlessthecardincludesoneofthefollowingrestrictions:
(1)NOTVALIDFOREMPLOYMENT
(2)VALIDFORWORKONLYWITHINSAUTHORIZATION
(3)VALIDFORWORKONLYWITHDHSAUTHORIZATION
2. PermanentResidentCardorAlien
RegistrationReceiptCard(FormI-551)
3. ForeignpassportthatcontainsatemporaryI-551stamportemporaryI-551printednotationonamachine-readableimmigrantvisa
2. IDcardissuedbyfederal,stateorlocalgovernmentagenciesorentities,provideditcontainsaphotographorinformationsuchasname,dateofbirth,gender,height,eyecolor,andaddress
4. EmploymentAuthorizationDocumentthatcontainsaphotograph(Form
I-766)
2. CertificationofBirthAbroadissuedbytheDepartmentofState(FormFS-545)
3. SchoolIDcardwithaphotograph
5. Foranonimmigrantalienauthorizedtoworkforaspecificemployerbecauseofhisorherstatus:
a.Foreignpassport;and
b.FormI-94orFormI-94Athathasthefollowing:
(1)Thesamenameasthepassport;
and
(2)Anendorsementofthealien'snonimmigrantstatusaslongasthatperiodofendorsementhasnotyetexpiredandtheproposedemploymentisnotinconflictwithanyrestrictionsor
limitationsidentifiedontheform. / 3. CertificationofReportofBirthissuedbytheDepartmentofState(FormDS-1350)
4. Voter'sregistrationcard
5. U.S.Militarycardordraftrecord
4. OriginalorcertifiedcopyofbirthcertificateissuedbyaState,county,municipalauthority,orterritoryoftheUnitedStatesbearinganofficialseal
6. Militarydependent'sIDcard
7. U.S.CoastGuardMerchantMariner
Card
8. NativeAmericantribaldocument
5. NativeAmericantribaldocument
9. Driver'slicenseissuedbyaCanadiangovernmentauthority / 6. U.S.CitizenIDCard(FormI-197)
7. IdentificationCardforUseofResidentCitizenintheUnitedStates(FormI-179)
Forpersonsunderage18whoareunabletopresentadocumentlistedabove:
8. EmploymentauthorizationdocumentissuedbytheDepartmentofHomelandSecurity
6. PassportfromtheFederatedStatesofMicronesia(FSM)ortheRepublicoftheMarshallIslands(RMI)withForm
I-94orFormI-94AindicatingnonimmigrantadmissionundertheCompactofFreeAssociationBetweentheUnitedStatesandtheFSMorRMI
10. Schoolrecordorreportcard
11. Clinic,doctor,orhospitalrecord
12. Day-careornurseryschoolrecord

ExamplesofmanyofthesedocumentsappearinPart8oftheHandbookforEmployers(M-274).

Refertotheinstructionsformoreinformationaboutacceptablereceipts.