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    I-9 - Venkatesh Kata

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    gopob43903

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    © All Rights Reserved
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    I-9 - Venkatesh Kata

    Uploaded by

    gopob43903
    6 views2 pages

    Original Title

    I-9_Venkatesh Kata

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    6 views2 pages

    I-9 - Venkatesh Kata

    Uploaded by

    gopob43903

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    © All Rights Reserved
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    of 2

    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)
    kata venkatesh N/A N/A
    Address (Street Number and Name) Apt. Number City or Town State ZIP Code
    9070 Irvine Center Dr N/A Irvine CA 92618
    Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number

    08/15/1980 - - kkatavenky@gmail.com 262-327-9875

    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): N/A


    ✔ 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): 09/30/2025
    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: N/A


    OR
    462236125A3
    2. Form I-94 Admission Number:
    OR
    3. Foreign Passport Number:
    N/A

    Country of Issuance: N/A

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


    k.venkatesh 08/21/2023
    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


    ab109fca-b84c-4f62-bdfb-80292e498c86
    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
    kata venkatesh N/A 4
    List A OR List B AND List C
    Identity and Employment Authorization Identity Employment Authorization
    Document Title Document Title Document Title
    Unexpired Foreign Passport N/A N/A
    Issuing Authority Issuing Authority Issuing Authority
    IND N/A N/A
    Document Number Document Number Document Number
    Z6631703 N/A N/A
    Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy)
    03/06/2032 N/A N/A
    Document Title
    Unexpired I-94 for Current Employer
    QR Code - Sections 2 & 3
    Issuing Authority Additional Information Do Not Write In This Space
    DHS
    Document Number
    462236125A3
    Expiration Date (if any) (mm/dd/yyyy)
    09/30/2025
    Document Title
    N/A
    Issuing Authority
    N/A
    Document Number
    N/A
    Expiration Date (if any) (mm/dd/yyyy)
    N/A
    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): 08/07/2023 (See instructions for exemptions)
    Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative
    Anila Kranthi 08/22/2023 Administrator
    Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
    Kranthi Anila It Minds Llc
    Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
    9070 Irvine Center Dr Ste 2 Irvine CA 92618

    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


    ab109fca-b84c-4f62-bdfb-80292e498c86

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