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Home My WebLink AboutI-9 Form exp2022 FILLABLE° Employment Eligibility Verification USCIS T Department of Homeland Security Form I-9 OMB No 1615-0047Expires �LgND SF�J U.S. Citizenship and Immigration Services 10/31/2022 ►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI -DISCRIMINATION NOTICE: It is illegal to discriminate against work -authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. rnap the°.,rtrsr aay. or empfoymenz, our not pproFe.acceprfng;a Jon orrer.� > = Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any) Address (Street Number and Name) I Apt. Number ; City or Town I State I ZIP Code Date of Birth (mm/dd/yyyy) I U.S. Social Security Number I Employee's E-mail Address I Employee's Telephone Number 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 boxes): E) 1. A citizen of the United States 0 2. A noncitizen national of the United States (See instructions) 0 3. A lawful permanent resident (Alien Registration Number/USCIS Number): V 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) Aliens authorized to work must provide only one of the following document numbers to complete Form 1-9: QR Code - Section 1 Do Not write in This space j An Alien Registration Number/USCIS Number OR Form 1-94 Admission Number OR Foreign Passport Number. j 1. Alien Registration Number/USCIS Number: OR 2. Form 1-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: Signature of Employee ! Today's Date (mm/dd/yyyy) I Prepatel> and/or Translator Certification (check one) li did not yse a prepa[er or translator A preparers) and/or (ranslator(s) assisted the employe1n complotlhg Section 1 T. (Fi tdfs bel :w must't a oornpletetl antl signe4l en preparers,aod/or`translators assisf, On Olriployee, ' Completrng $action 1,) attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. 0 Employer Completes A-ext Page e Form 1-9 10 21/2019 Page] of 3 Employment Eligibility Verification USCIS Department of Homeland Security Form I-9 OMB N0 1615-0047Expires >t � ��qND SE�'J U.S. Citizenship and Immigration Services 10i31/2022 Section 2. Employer or Authorized 'Representative Review and Verification (Employees of their authorized rep►esentatnfe must Complete" and sign Section 2 within 3 business days Of the employee's first dayof employment. You must physically examine one document hom Lrsf. A OR a ;cornbinatfon of one document from Lh0 8 and one document from List C as listed on the "Lists of Acceptable' Documents.') , Last Name (Family Name) First Name (Given Name) I M.I. ; Citizenship/Immigration Status Employee Info from Section 1 List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization Document Title Issuing Authority uocument INumoer Expiration Date (if any) (mm/dd/yyyy) Document Title Document Number Expiration Date (if any) (mm/dd/yyyy) Document Title Issuing Authority r Expiration Date (if any) (mm/dd/yyyy) Document Title Issuing Authority Document Title Issuing Authority Document Number Document Number Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy) Additional Information OR Code - Sections 2 & 3 Do Not write In This Space Certification: I attest, under penalty of perjury, that (1) 1 have examined the document(s) presented by the above -named employee, (2) the above -listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions) Signature of Employer or Authorized Representative Today's Date (mm/ddlyyyy) Title of Employer or Authorized Representative i Human Resources Analyst Last Name of Employer or Authorized Representative I First Name of Employer or Authorized Representative Employer's Business or Organization Name i McKay Babette City of Saratoga Employer's Business or Organization Address (Street Number and Name) City or Town ;State ZIP Code 13777 Fruitvale Ave Saratoga CA 95070 'Section 3. Reverificat on And Rehires (To be completed and signed by employer or authorized reptesentative;) A. New Name (if applicable) B. Date of Rehire (if applicable) I Last Name (Family Name) I First Name (Given Name) Middle Initial I Date (mm/dd/yyyy) IC. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy) I I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the documents) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative Form 1-9 10/21/2019 Page 2 of 3 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. I LIST A LIST B LIST C Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization Employment Authorization OR AND 1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number 4: fit: " ` .t .` State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address j j card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION 2. Permanent Resident Card or Alien Registration Receipt Card (Form 1551) 3. Foreign passport that contains a temporary 1-551 stamp or temporary 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, eye color, and address 1-551 printed notation on a machine readable immigrant visa (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 4. Employment Authorization Document that contains a photograph (Form 1-766) 2• ! Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240) 3. School ID card with a photograph 5. For a nonimmigrant alien authorized 3. Original or certified copy of birth I 4. Voter's registration card to work for a specific employer 4' certificate issued by a State, because of his or her status: a. Foreign passport; and b. Form 1-94 or Form 1-94A that has county, municipal authority, or territory of the United States bearing an official seal 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner 4. Native American tribal document j the following: _' (1) The same name as the passport and (2) An endorsement of the aliens x; 8, Card Native American tribal document 5. U.S. Citizen ID Card (Form I-197) I 6. Identification Card for Use of 9. Driver's license issued by a Canadian j nonimmigrant status as long as :'; Resident Citizen in the United j that period of endorsement has government authority States (Form 1-179) not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form i, For persons under age 18 who are unable to present a document listed above: 7. ( Employment authorization document issued by the Department of Homeland Security 6. Passport from the Federated States of Micronesia (FSM) or the Republic 10. School record or report card 11. Clinic, doctor, or hospital record of the Marshall Islands (RMI) with Form 1-94 or Form 1-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record j Compact of Free Association Between the United States and the FSM or RMI i I Examples of many of these documents appear in the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts. Form f-9 10/21/2019 Page 3 or