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
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) M.I. First Name (Given Name) Employee Info from Section 1 Citizenship/Immigration Status
List A Identity and Employment Authorization
OR
Identity List B
AND
List C
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 Do Not Write In This Space
Additional Information
Issuing Authority
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
State ZIP Code
Employer's Business or Organization Address ( Street Number and Name ) City or Town
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial B. Date of Rehire (if applicable) 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.
Expiration Date (if any ) (mm/dd/yyyy)
Document Title
Document Number
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
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Form I-9 10/21/2019
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