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Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

USCIS I-9 OMB No. 1615-0047 Expires 08/31/2019

▸ START HERE: Read instructions carefully before completing this form. The instructions must be followed 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-eligible individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. A refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may 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)Text

First Name (Given Name)Text

Middle InitialText

Other Last Names Used (if any)Text

Address (Street Number and Name)Text

Apt. NumberText

CityText

StateText

ZIP CodeText

Date of Birth (mm/dd/yyyy)Text

U.S. Social Security NumberText

Employee's E-mail AddressText

Employee's Telephone NumberText

I am aware that federal law provides for imprisonment 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):

1. A citizen of the United States 2. A noncitizen national of the United States 3. A lawful permanent resident Alien Registration Number/USCIS Number: 4. An authorized alien Alien Registration Number/USCIS Number (expiration date, if applicable, mm/dd/yyyy) Social Security Number (expiration date, if applicable, mm/dd/yyyy)

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: QR Code - Section 1
Do Not Write In This Space

1. Alien Registration Number/USCIS Number:

OR

2. Form I-94 Admission Number:

OR

3. Foreign Passport Number:

Country of Issuance:

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

USCIS I-9 OMB No. 1615-0047 Expires 08/31/2019

Section 2. Employer or Authorized Representative Review and Verification (Employers or Authorized Representatives must complete Section 2 as soon as practicable after the employee begins work for pay.)

The employee must present one document from List A OR one document from List B and one document from List C. The employer or authorized representative must examine the document(s) presented for the genuineness and record the information below.

Document Title (List A)Text

Issuing AuthorityText

Document NumberText

Expiration Date (mm/dd/yyyy)Text

Document Title (List B)Text

Issuing AuthorityText

Document NumberText

Expiration Date (mm/dd/yyyy)Text

Document Title (List C)Text

Issuing AuthorityText

Document NumberText

Expiration Date (mm/dd/yyyy)Text

I attest, under penalty of perjury, that the document(s) presented by the above-named employee relate to the employee and appear to be genuine and that the employee is authorized to work in the United States.

Signature of Employee

Date of First Day of Employment (mm/dd/yyyy)

Signature of Employer or Authorized Representative

Date Signed (mm/dd/yyyy)

Print Name of Employer or Authorized Representative

Title of Employer or Authorized Representative

First Day of Employment (mm/dd/yyyy)

Organization Name

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

USCIS I-9 OMB No. 1615-0047 Expires 08/31/2019

Section 3. Reverification and Rehires (Employers or Authorized Representatives complete this section only when reverification of an employee's work authorization is required.)

Name of Employee (Last, First, M.I.)Text

Date of Rehire (mm/dd/yyyy)Text

Employee's Date of Birth (mm/dd/yyyy)Text

Document TitleText

Issuing AuthorityText

Document NumberText

Expiration Date (mm/dd/yyyy)Text

Country of IssuanceText

New or Previous Expiration DateText

If the employee's work authorization has expired, the employer or authorized representative must record the information from the document(s) presented that establishes the employee's continuing work authorization in the United States.

Reverification required — document(s) examined and recorded above Rehire date entered — employee resumed work for the same employer on the date indicated No reverification required at this time

Signature of Employer or Authorized Representative

Date (mm/dd/yyyy)

Print Name of Employer or Authorized Representative

Title of Employer or Authorized Representative

Organization Name

Telephone Number

This section must be completed by the employer or authorized representative at the time the information is recorded and retained in accordance with the applicable regulations.

Human Verification