Form I-9 Employment Eligibility Verification

Instructions: Complete all applicable sections of this form. Your submission will be converted to PDF and sent to HR. Fields marked with * are required.

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

Address (Street Number and Name) *

Apt. Number

City or Town *

State *

ZIP Code *

Date of Birth *

U.S. Social Security Number Optional (required if E-Verify employer)

Employee's Email Address

Employee's Telephone Number

Citizenship / Immigration Status *

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

3. A lawful permanent resident

USCIS Number or Alien Registration Number

4. An alien authorized to work

Expiration Date (if applicable)

Alien Registration Number / USCIS Number

Form I-94 Admission Number

Foreign Passport Number

Country of Issuance

Signature of Employee * Type your name, then draw your signature below.

Today's Date *

Draw Signature of Employee *

Sign here using your mouse or finger

Draw your signature in the box above.

Supplement A — Preparer and/or Translator Certification

Complete this section if the employee used a preparer or translator to complete Section 1. Leave blank if not applicable.

A preparer and/or translator assisted the employee in completing Section 1.

Section 2. Employer or Authorized Representative Review and Verification

Employers must complete Section 2 by examining evidence of identity and employment authorization within 3 business days of the employee's first day of employment.

Enter document information from List A (which establishes both identity and employment authorization) OR one document from List B (identity) AND one from List C (employment authorization).

List A — Identity and Employment Authorization

Document Title

Issuing Authority

Document Number

Expiration Date

List B — Identity

Document Title

Issuing Authority

Document Number

Expiration Date

List C — Employment Authorization

Document Title

Issuing Authority

Document Number

Expiration Date

Additional Information

Employee's First Day of Employment

Signature of Employer or Authorized Representative

Title

Date

Employer's Business or Organization Name

Employer's Business or Organization Address (Street, City, State, ZIP)

Supplement B — Reverification and Rehires

Complete this supplement if reverification or rehire applies. Leave blank if not applicable.

This is a reverification or rehire.

This form will be converted to a PDF matching the official I-9 format and sent to [email protected] and [email protected].

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