Employment Eligibility Verification Department of Homeland SecurityU.S. Citizenship and Immigration Services "*" indicates required fields Step 1 of 4 25% URLThis field is for validation purposes and should be left unchanged.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 1-9 no later then the frat day of employment, but not before accepting e job offer) Last Name (Family Name)*First Name (Given Name)*Middle Initial*Other Last Names Used (if any)*Address Street Address Apt. Number City or Town AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth (mm/dd/yyyy) MM slash DD slash YYYY U.S. Social Security NumberEmployee's E-mail Address* Employee's Telephone Number* 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):Citizen A citizen of the United States A noncitizen national of the United States A lawful permanent resident (Alien Registration Number/USCIS Number): An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): 3rd option4thSome aliens may write "N/A" in the expiration date field. (See instructions) 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 1-94 Admission Number OR Foreign Passport Number.Form I-94 Admission NumberORForeign Passport NumberORAlien Registration Number/USCIS NumberCountry of IssuanceQR Code - Section 1 Do Not Write In This SpaceMax. file size: 1 GB. Signature of EmployeeToday's Date (mm/dd/yyyy) MM slash DD slash 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 TranslatorToday's Date (mm/dd/yyyy) MM slash DD slash YYYY Last Name (Family Name)*First Name (Given Name)*Address (Street Number and Name) Street Address City or Town AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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.")Employee Info from Section 1Last Name (Family Name)*First Name (Given Name)*M.I.*Citizenship/Immigration StatusList A Identity and Employment AuthorizationDocument TitleIssuing AuthorityDocument NumberExpiration Date (if any)(mm/dd/yyyy) MM slash DD slash YYYY Document TitleIssuing AuthorityDocument NumberExpiration Date (if any)(mm/dd/yyyy) MM slash DD slash YYYY Document TitleIssuing AuthorityDocument NumberExpiration Date (if any)(mm/dd/yyyy) MM slash DD slash YYYY ORList B IdentityDocument TitleIssuing AuthorityDocument NumberExpiration Date (if any)(mm/dd/yyyy) MM slash DD slash YYYY ANDList C Employment AuthorizationDocument TitleIssuing AuthorityDocument NumberExpiration Date (if any)(mm/dd/yyyy) MM slash DD slash YYYY Additional InformationQR Code - Sections 2 & 3 Do Not Write In This SpaceMax. file size: 1 GB. 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) MM slash DD slash YYYY (See instructions for exemptions)Signature of Employer or Authorized RepresentativeToday's Date(mm/dd/yyyy) MM slash DD slash YYYY Title of Employer or Authorized RepresentativeLast Name of Employer or Authorized RepresentativeFirst Name of Employer or Authorized RepresentativeEmployer's Business or Organization NameEmployer's Business or Organization Address (Street Number and Name) Street Address City or Town AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 InitialB. Date of Rehire (if applicable)Date (mm/dd/yyyy) MM slash DD slash 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.Document TitleDocument NumberExpiration Date (if any) (mm/dd/yyyy) MM slash DD slash YYYY 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 RepresentativeToday's Date (mm/dd/yyyy) MM slash DD slash YYYY Name of Employer or Authorized Representative 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 Documents that Establish Both Identity and Employment Authorization U.S. Passport or U.S. Passport Card Permanent Resident Card or Alien Registration Receipt Card (Form I-551) Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa Employment Authorization Document that contains a photograph (Form I-766) For a nonimmigrant alien authorized to work for a specific employer because of his or her status: Foreign passport; and Form I-94 or Form I-94A that has: The same name as the passport; and 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. 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 that Establish Identity 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 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 School ID card with a photograph Voter's registration card U.S. Military card or draft record Military dependent's ID card U.S. Coast Guard Merchant Mariner Card Native American tribal document Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: School record or report card Clinic, doctor, or hospital record Day-care or nursery school record LIST C Documents that Establish Employment Authorization A Social Security Account Number card, unless the card includes one of the following restrictions: NOT VALID FOR EMPLOYMENT VALID FOR WORK ONLY WITH INS AUTHORIZATION VALID FOR WORK ONLY WITH DHS AUTHORIZATION Certification of Birth Abroad issued by the Department of State (Form FS-545) Certification of Report of Birth issued by the Department of State (Form DS-1350) Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal Native American tribal document U.S. Citizen ID Card (Form I-197) Identification Card for Use of Resident Citizen in the United States (Form I-179) Employment authorization document issued by the Department of Homeland Security Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts.
