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Employment Eligibility Verification uscls <br /> Department of Homeland Security Form 1-9 <br /> U.S. Citizenship and Immigration Services OMB No. 1615-00,17 <br /> f:xpires 08.3,i2019 <br /> To <br /> 0 u <br /> � Y. <br /> Employee Info frsm'Secti+sn 7 fast iJame{Fafiily Name) First Name Oven Name) <br /> :.M.4. CiL-ensh;pll.T migration Status <br /> List A <br /> OR List B AND List C <br /> Identity and Employment Authorization Identity Employment Authorization <br /> --unent THA Document 7 ill� Doomnent Title , -1% <br /> • Issuing Au` ons Issuing Authority <br /> Document Nuert�er -77 rJoc.-Me?PU <br /> Occumeg Number <br /> Exp:raticri Dale(d-?ny)(mnVd&yr <br /> yy) EXPI,2t!cn Date(if x7y)(mrnlddly.6y) Cata(if any)(rrrrlddhn-yyi <br /> Document Title <br /> Issuing Authority Additional Information OR 3 <br /> 00 N01 Wr-x In Tn*SLsee <br /> Document Number _` <br /> Expiration Date;if any)(mrWddlyyyy) <br /> Document Titin. <br /> II <br /> Issuing Author 1 <br /> Document Number <br /> Expiration Date(it any)(mralddlyyyy) <br /> Certification:I attest,under penalty of perjury,that(1)1 have examined the document(s)presented by the above-named employee, <br /> (2)the above-Wed document(s)appear to be genuine and to relate to the employee named,and(3)to the best of my knowledge the <br /> employee Is authorized to Vicirk in the UnItec! States. <br /> .,,�oyee's first day of employment(mmIddlyyyy): (See instructions for exemptions) <br /> Signature 'f Emplo. or Auth&izecw�,Penalva Today's DaIe(mWdcVyyyy; tje 0 �mqoyer or Authorized Representative <br /> Last Name of ErnployarorAu ofizedReprese-itative :FirstN cf Employer cr.ILqhcr�-zed Representa Employees Bu Sze <br /> n (I tL t0 A-Al'ort.Nanij,, <br /> 0- pra % -�So i 7 1 r <br /> M�— —7 P�--Eo K <br /> Emp yers 9 Organ, tion Address ;reef Number ond Name) Cit v 01,Town state Z.P Code <br /> 11C- <br /> L <br /> SM <br /> if appikable) <br /> A.-New-Nernef 113.Date of Rehire(if appr1:7able) <br /> Last Name(Family Name) First Name(Given Name) Middle nitial Date(mrWddlvyyv) <br /> -,-Y . ....�'9�'Yy"Y' <br /> 1 11 <br /> -f L�211Y?l cr`1,Lqhrzad Rp,,,r, <br /> C--If the:pm* nt <br /> WW <br /> . _,,yee'q previoussra, - --P;qM8nt-,aulho: exojwd.Provide the�i�IaUorfor ft ctocument or—racelpt that establishes <br /> 0166tiuirig efilojorfik iiiiftez-4ilon qnlii provided <br /> .Y) <br /> Document Title -=-=ent Nurnber -j-.41e(ifeny)fh,,-.,1dd1yYYYyyy) <br /> I attest,under penalty of periurl,that to the hest -a f my knowledge,this employee is authorized to work In the United States,and if <br /> the employee presented document(s),the document(s)I have examined appear to be genuine and to relate to the indwidua'... <br /> Signature of Employer or Authorized Representativa I Today's Dalr (mnVddlyyyy) Name of Employer or Authcfted Represertative <br /> Form 1-9 11/14/2016 N Page 2 of 3 <br />