Print Name: Last
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First
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Middle Initial
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Maiden Name
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Address (Street Name and Number)
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Apt. #
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Birth Date (month/day/year)
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City
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State
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Zip Code
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Social Security number
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| 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. |
I attest, under penalty of perjury, that I am (Check one of the following)
A citizen or national of the United States
An Alien authorized to work until
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(Alien # or Admission #)
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Employee's Signature
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Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
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Print Name Preparer's/Translator's Signature
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Date (month/day/year)
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Address (Street Name and Number, City, State, Zip Code
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| _____________________________________________________ |
| Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if any, of the document(s).
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| CERTIFICATION - l attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year)
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and that to the best of my knowledge is eligible to work in the United States. (State employment agencies may omit the date the employee began employment.) |
| Signature of Employer or Authorized Representative
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Print Name
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Title
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Business or Organization Name
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Address (Street Name and Number, City, State, Zip Code)
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Date (month/day/year)
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| Section 3. Updating and Reverification. To be completed and signed by employer. |
A. New Name (if applicable)
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Date of Rehire (month/day/year) if applicable
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| C. If employee's previous grant work authorization has expired, provide the information below for the documentation that establishes current employment eligibility. |
| Document Title:
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Document #
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Expiration Date (if any):
Date (month/day/year)
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| l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual. |
Signature of Employer or Authorized Representative
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Date (month/day/year)
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| _____________________________________________________ |
