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i9 1.png

Read instructions carefully before completing this form. The instructions must be available during completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination.


Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)

Name *
Name
Address *
Address
Date of Birth *
Date of Birth
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. *
Today's Date *
Today's Date
I attest, under penalty of perjury, that I am (check one of the following): *
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
Preparer's Name *
Preparer's Name
Preparer's Address *
Preparer's Address
Today's Date
Today's Date
Section 2. Identification: Enter information from one document on List A OR one document from List B and one from List C, as listed on the bottom of this form, and record the title, number, and expiration date, if any, of the document(s).
List A
List A Expiration Date
List A Expiration Date
OR List B
List B Expiration Date
List B Expiration Date
AND List C
List B Expiration Date
List B Expiration Date
CERTIFICATION: I attest, under penalty of perjury, that the document(s) information provided are genuine and relate to the employee named, that the employee began employment on the date listed below and that to the best of my knowledge the employee is authorized to work in the United States. (State employment agencies may omit the date the employee began employment.)
Today's Date
Today's Date
Employer or Authorized Representative
Employer or Authorized Representative
Business or Organization Address
Business or Organization Address