~Dual Comp Staff Provider Onboarding Binder 06.26.20

USCIS Form I-9

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

OMB No. 1615-0047 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)

State ZIP Code

Address (Street Number and Name)

City or Town

Apt. Number

U.S. Social Security Number

Employee's Telephone Number

Employee's E-mail Address

Date of Birth (mm/dd/yyyy)

-

-

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 4. An alien authorized to work until Some aliens may write "N/A" in the expiration date field.

(See instructions) (expiration date, if applicable, mm/dd/yyyy): (Alien Registration Number/USCIS Number):

QR Code - Section 1 Do Not Write In This Space

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: 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)

State ZIP Code

City or Town

Address (Street Number and Name)

Employer Completes Next Page

Page 1 of 3

Form I-9 10/21/2019

Welcome 5

Made with FlippingBook - Online catalogs