Employment Eligibility Verification



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Form I-9 Instructions 03/08/13 N EMPLOYERS MUST RETAIN COMPLETED FORM I-9 DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS Page 1 of 9 All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checking one of the following four boxes provided on the form: 1.. Form I-9 Instructions 03/08/13 N Page 4 of 9 Some employees may write "N/A" in the space provided for the expiration date in Section 1 if they are aliens whose employment authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau).. Number Address (Street Number and Name) Date of Birth (mm/dd/yyyy) Middle Initial Other Names Used (if any) First Name (Given Name) City or Town State U.S. Social Security Number E-mail Address - Zip Code 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.. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.) Employee Last Name, First Name and Middle Initial from Section 1: List A OR AND List B List C Identity and Employment Authorization Document Title: Identity Document Title: Employment Authorization Document Title: Issuing Authority: Issuing Authority: Issuing Authority: Document Number: Document Number: Document Number: Expiration Date (if any)(mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy): Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mm/dd/yyyy): 3-D Barcode Do Not Write in This Space 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) a

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