Employment Eligibility Verification USCIS

Department of Homeland Security Form I-9

OMB No. 1615-0047
U.S. Citizenship and Immigration Services Expires 10/31/2022

►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 I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee'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):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident (Alien Registration Number/USCIS Number):

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)
QR Code - Section 1
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: Do Not Write In This Space
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR
2. Form I-94 Admission Number:
OR
3. Foreign Passport Number:
Country of Issuance:

Signature of Employee Today's Date (mm/dd/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 Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 10/21/2019 Page 1 of 3

 Employment Eligibility Verification USCIS
Department of Homeland Security Form I-9
OMB No. 1615-0047
U.S. Citizenship and Immigration Services Expires 10/31/2022

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.")
Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status
Employee Info from Section 1

List A OR List B AND List C

Identity and Employment Authorization Identity Employment Authorization
Document Title Document Title 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

QR Code - Sections 2 & 3

Issuing Authority Additional Information Do Not Write In This Space

Document Number

Expiration Date (if any) (mm/dd/yyyy)

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) 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): (See instructions for exemptions)
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) B. Date of Rehire (if applicable)
Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/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 Title Document Number Expiration Date (if any) (mm/dd/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 Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

Form I-9 10/21/2019 Page 2 of 3

 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 LIST B LIST C

Documents that Establish Documents that Establish Documents that Establish
Both Identity and Identity Employment Authorization
Employment Authorization OR AND

1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number
State or outlying possession of the card, unless the card includes one of
2. Permanent Resident Card or Alien
United States provided it contains a the following restrictions:
Registration Receipt Card (Form I-551)
photograph or information such as (1) NOT VALID FOR EMPLOYMENT
name, date of birth, gender, height, eye
3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH
temporary I-551 stamp or temporary INS AUTHORIZATION
I-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH
readable immigrant visa government agencies or entities, DHS AUTHORIZATION
provided it contains a photograph or
4. Employment Authorization Document information such as name, date of birth, 2. Certification of report of birth issued
that contains a photograph (Form gender, height, eye color, and address by the Department of State (Forms
I-766) DS-1350, FS-545, FS-240)
3. School ID card with a photograph
5. For a nonimmigrant alien authorized 3. Original or certified copy of birth
to work for a specific employer 4. Voter's registration card certificate issued by a State,
because of his or her status: county, municipal authority, or
5. U.S. Military card or draft record territory of the United States
a. Foreign passport; and
6. Military dependent's ID card bearing an official seal
b. Form I-94 or Form I-94A that has
the following: 7. U.S. Coast Guard Merchant Mariner 4. Native American tribal document
(1) The same name as the passport; Card
5. U.S. Citizen ID Card (Form I-197)
and
8. Native American tribal document
(2) An endorsement of the alien's 6. Identification Card for Use of
nonimmigrant status as long as 9. Driver's license issued by a Canadian Resident Citizen in the United
that period of endorsement has government authority States (Form I-179)
not yet expired and the
proposed employment is not in For persons under age 18 who are 7. Employment authorization
conflict with any restrictions or unable to present a document document issued by the
limitations identified on the form. Department of Homeland Security
listed above:
6. Passport from the Federated States
10. School record or report card
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with 11. Clinic, doctor, or hospital record
Form I-94 or Form I-94A indicating
nonimmigrant admission under the 12. Day-care or nursery school record
Compact of Free Association Between
the United States and the FSM or RMI

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form I-9 10/21/2019 Page 3 of 3