0MB No.
Department of
U.S.
l615-0047 Expires 08/31/12
Form 1-9, Employment
Eligibility Verification
homeland Security
Citizenship and Immigration Services
Read instructions carefully before completing this form. The instructions must be available during completion of this form.
ANTE-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authoriied individuals. Employers CANNOT
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification (To be completed and sivied by employee at the time employment begins.)
Print Name:
\ddress
Last
First
SIJtel Same
Middle Initial
and Aunt he,,
City
State
Apt
Date of Binh
Zip Code
Social Security
A
noncitizen national of the
Employees Stgnature
0/pt 1 urt
lb
United States tvee instructions/
alien authorized to work ( Alien or Admission )
expiration date, if applicable
month dat-tear)
Date (monlit.
it
tat
ii 1 1
/ itt ot
ompl
‘To he eontpletedo,tdagneti
it nt aid rh tilt
r,
fl at of i/ti
Preparer’sTranslator’s Signature
Address
(Street
0
A lawful permanent resident (Alien 4)
Sn
I
da tear,
A cittzen of the United States
until
Preparer and/or Translator Certification
(manOr
I attest, under penalty of petiurv. that I am (check one of the following):
.
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.
/
Maiden same
if
‘
—
daitear)
Section I is prepared he a ikivolt other than the empIolee) I
i or no /Ot 1, / 0
lit ill/o, molt t
11 t/t itt 1 0, 7
arrest.
under
Print Name
Name and Number, City, Stale, Z(o Codej
Date (month dav/vear
Section 2. Employer Review and Verification (To he completed and sign cii hi: employer. Examine one document from List .4 OR
examine one document /romn List B and one/rain List C. u.s listed on the reverse of this /brm. and record the title, number, and
expiration date. if an v. o/the documenri I.)
List A
OR
List B
AND
List C
Document title:
Issuing authortt
Document 4:
Fxptratton
Date (if ant.)
Document P
Fxptrstti n D it
Cant.
CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named ernploee. that
the abox c-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
nonth-dert: tear
and that to the best of my knowledge the employee is authorized to work in the United States. (State
employment agencies mar omit the date the employee began employment.)
(gnatire of Etgpio.er or Authort,ed Representatise
Print Name
Tit.
I1Lp
Business or Oreanizatiod Name and Address (Street. Same and Number City, Stair Zip (tvde)
3
‘‘‘‘
Date (inonth/duy/ear)
-
ia&(,
/ / DIQi(P fflt )(y,tv,/( IL
Section 3. Updating and Rev erification To he completed and signeli he entployerj
A, New Name
(.‘
‘it
,tpr,iieahlei
If empios CC’S previous grant at a ark auth-artzat:c’t: It,a’ xp:red. prar dc
B oCtirtiCtt f:te:
B I.)ata of Rehtre fnt’.nrP
It/C
:t:iftrmat/at:
.i,c : ei) fj/aes’ii. ,lha
Pe)’:v for the docume-tit that estabi/she” clorent cuiploymetit authorizat/on
‘.:p/rat:otl I).:te
that to th hxt of mx knowkd,, thisimploxci. is .iuthort,td to work in tht Lniftd %tats and
document(s), the documentt ) I base examined appear to be genuine and to relate to the indixidual.
Signature of Employer or Au.thor/zcd Representative
I attest undrr pulalh of
pirurx
‘:1 an:::
if titi.
emplosit presrnted
Form 1-9 (Rev. 08 909) Y Page 4
LISTS OF ACCEPT BLE DOCUMENTS
All documents must be unexpired
LIST A
Documents that Establish Both
Identity and Employment
Authorization
LIST B
OR
2. Permanent Resident Card or Alien
Registration Receipt Card (Form
1-55 I)
3. Foreign passport that contains a
temporary 1-55 1 stamp or temporary
1-551 printed notation on a machinereadable immigrant visa
4. EmpI ovment Authorization Document
that comains a photograph (Form
1-766
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (kM I) with
Form 1-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association
Between the United States and the
FSM or RMI
Documents that Establish
Employment Authorization
Documents that Establish
Identity
1. US. Passport or U.S. Passport Card
5. In the case of a nonimmigrant alien
authorized to work for a specific
employer incident to status, a foreign
passport with Form 1-94 or Form
1-94A bearing the same name as the
passport and containing an
endorsement of the alien’s
nonimmigrant status, as long as the
period of endorsement has not yet
expired and the proposed
employment is not in conflict with
any restrictions or hmitatons
identified 011 the form
LIST C
AND
Drivers license or ID card issued by
a State or outlying possession of the
Lnted States pro\ ided it contains a
photograph or information such as
name, date of birth. gender, height.
eye color, and address
2. ID card issued by federal, state or
local government agencies or
entities, provided it contains a
photograph or information such as
name, date of birth, gender, height,
eve color, and address
3. School ID card with a photograph
4. \oter’s registration card
5. L’S. Militar card or draft record
6. Military dependents ID card
7. ES. Coast Guard Merchant Mariner
Card
I. Social Security Account Number
card other than one that specifies
on the face that the issuance of’ the
card does not authorize
empioment in the Enited States
2. Certification of Birth Abroad
issued by the Department of State
(Form FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a State.
county, municipal authority, or
territory of the [nited States
hearing an official seal
‘
Native Amertean tribal document
8. Native American tribal document
9. Drivers license issued by a Canadian
ito\ ernnient authoratv
For persons under age 18 sbo
are unable to present a
document listed aboe:
10. School record or report card
Ii. CIi.nic, doctor, or hospital record
6. U.S. Citizen ID Card Form 1-197)
7. Idenufication Card for [se of
Resident Citizen ifl the United
States Form 1-179)
8. Employment authorization
document issued by the
Department of Homeland Security
1 2. Davcare or nursery school record
Illustrations of many of these documents appear in Part 8 of the handbook for Employers (XI-274)
F-or: t
Rev. (IS. fl:’l9
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