Laserfiche WebLink
Employment Eligibility Verification USCIS <br /> Department of Homeland Security Form 1-9 <br /> 0\113 No 1615-0047g <br /> U.S. Citizenship and Immigration Services <br /> 4�n ss Expims 08 31 20I9 <br /> ►$TART HERE:Read Instructions carefully before completing this form.The Instructions most be available,either In paper or electronically, <br /> during completion of this form.Employers are liable for errors in the completion of this fors. <br /> ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Emp overs CANNOT specify which <br /> document(s)an employee may present to establish employment authorization and identity.The refusal to hire or continue to employ <br /> an individual because the documentation presented has a future expiration date may also constitute illegal d,scrimination. <br /> ­ r ex _ <br /> - —. ,"E'. ". ._ sr y Y` Ai �ecort`1 :fFarlc9 no later. <br /> Last Name(Fam <br /> ily Name) 4Fi mt Name(Given Name) .Midd-a Initial Other'tea st Names Usad(if any) <br /> Lr <br /> , _ <br /> Addrgss(Street Numberead Name) *. t Apt.Number .City or Town <br /> Date of Birth(mm/dd/yyyy) U.S.1Social Security Number -I Employee's E-mail Address 1 Employea's Telephone Number <br /> 1 am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents In <br /> connection with the completion cf this form. <br /> I attest,.cinder penalty of perjury,that I am(check one of the following boxes): <br /> 'i,A citizen of the United States <br /> ❑ 2.A noncitizon national of the Unite,.States(Sao instruct°ons) <br /> 3.A lawful permanent resident (Alien Registration NurnberJUSCIS Number): <br /> 4-An alien authorized to work until (expiration date,it applicab'e,mmlddlyyyy): <br /> Some aliens may write'NIA"in the expiration date field. (See instructions) <br /> Aliens authorized to work must provide only one of the follmi-ng docunment numbers to complete Four 1-9: QR Cc-do-50=0n s <br /> i <br /> An Alien Registration NumberlUSC1S Number OR corm 1-94 Admission Number OA.Foreign Passport Number. I DO NW W.7te 1^ h:s SpaM <br /> 4.Alien Regis{sation NumberlUSCIS Numbe. <br /> OR <br /> 2.Form 1-94 Admission Number: j <br /> OR <br /> 3.Foreign Passport Number. ; <br /> Country of Issuance: <br /> 5ignatare of Employee Today's Dave(mm/dc*yyy) 1 <br /> PR <br /> Me <br /> T - <br /> ��. � � '�fj• V -. 0_0 <br /> Signature <br /> Y <br /> I attest, under penalty of perjury,that I have assisted in the completion of Section i of this farm and that to the best of ry <br /> knowledge the information is true and correct. <br /> Signature of Preparer or Translator - I Today's Date(rrWdd/yyyy) <br /> Last Name(Family Name) f=irst Name(Given Name) <br /> Address(Street Number and Name) City or Town State !ZIP C'cdn <br /> � I <br /> 49M L <br /> ; <br /> Form 1-9 11/14/2016 N Page I of 3 <br />