Employment Eligibility Verification Form Template (I-9)

Employment Eligibility Verification (Form I-9)
U.S. Department of Homeland Security
U.S. Citizenship and Immigration Services

Section 1: Employee Information and Attestation

(To be completed by the employee)

• Last Name (Family Name): __________________
• First Name (Given Name): __________________
• Middle Initial: ______________
• Other Last Names Used (if any): __________________
• Address (Street Number and Name): __________________
• Apt. Number: _______
• City or Town: __________________
• State: __________________
•  ZIP Code: __________________
•  Date of Birth (mm/dd/yyyy): __________________
• U.S. Social Security Number: __________________
• Employee’s Email Address (optional): __________________
• Employee’s Telephone Number (optional): __________________
  
  

I attest, under penalty of perjury, that I am (check one of the following):

• A citizen of the United States
• A noncitizen national of the United States
• A lawful permanent resident (Alien Registration Number/USCIS Number): __________________
•  An alien authorized to work (Expiration Date, if applicable, mm/dd/yyyy): __________________
  
  

Employee’s Signature: __________________
Date: __________________

Section 2: Employer or Authorized Representative Review and Verification

(To be completed by the employer)

Employer Information:

• Employer’s Business Name: __________________
• Employer’s Business Address: __________________
• City: __________________
  State: __________________
•  ZIP Code: __________________
  
  

Documents that Establish Employment Authorization:

• List A:
  Document Title: __________________
  Issuing Authority: __________________
  Document Number: __________________
  Expiration Date (if any): __________________
  OR
• List B (Identity):
  Document Title: __________________
  Issuing Authority: __________________
  Document Number: __________________
  Expiration Date (if any): __________________
  AND
• List C (Employment Authorization):
  Document Title: __________________
  Issuing Authority: __________________
  Document Number: __________________
  Expiration Date (if any): __________________
  
  

Certification:

I attest, under penalty of perjury, that the above-listed documents appear to be genuine and to relate to the employee named, and that, to the best of my knowledge, the employee is authorized to work in the United States.

Employer’s Signature: __________________

Date: __________________

Section 3: Reverification and Rehires

(To be completed and signed by the employer, if applicable)

• Name of Employee: __________________
• Date of Rehire (if applicable): __________________
• Document Title: __________________
• Document Number: __________________
• Expiration Date (if any): __________________
  
  

Employer’s Signature: __________________
Date: __________________

Instructions:

1. Employee: Complete Section 1 at the time of hire. Provide valid documentation from the Lists of Acceptable Documents.
2. Employer: Verify the documents and complete Section 2 within three business days of the employee’s first day of employment.
3. Reverification: Complete Section 3 for reverification or rehires.
   
   

Privacy Act Statement:

• Authority for collection of this information is found in 8 U.S.C. § 1324a.
• This information will be used to verify your employment authorization.
• The information you provide may be disclosed to the Department of Homeland Security (DHS) or other law enforcement authorities.