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USCISForm I-9OMB No. Street Address -0047Expires Street Address /31/2022Employment Eligibility VerificationDepartment of Homeland SecurityU.S. Citizenship and Immigration ServicesForm I-9 10/21/2019 Page 1 of 3START 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. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.) 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 E-mail Address Employee's Telephone Number 1. A citizen of the United States2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident4. An alien authorized to work until(See instructions)(expiration date, if applicable, mm/dd/yyyy):(Alien Registration Number/USCIS Number):Some aliens may write "N/A" in the expiration date field. 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): Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. 1. Alien Registration Number/USCIS Number:2. Form I-94 Admission Number:3. Foreign Passport Number:Country of Issuance:ORORQR Code - Section 1Do Not Write In This SpaceSignature of Employee Today's Date (mm/dd/yyyy)Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.) I 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.Signature of Preparer or Translator Today's Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name)Address (Street Number and Name) City or Town State ZIP Code Employer Completes Next PageC1 SWANNIE LN N/A EAST WINDSOR NJ 0852009/28/1963 XXX-XX-XXXX EMAIL AVAILABLE PHONE NUMBER AVAILABLE N/AN/AN/AN/AN/AN/A07/15/2022Gillespie Kevin D N/AForm I-9 10/21/2019 Page 2 of 3USCISForm I-9OMB No. 1615-0047Expires 10/31/2022Employment Eligibility VerificationDepartment of Homeland SecurityU.S. Citizenship and Immigration ServicesSection 2. Employer or Authorized Representative Review and Verification(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")Last Name (Family Name) First Name (Given Name) M.I. Employee Info from Section 1Citizenship/Immigration StatusList AIdentity and Employment Authorization Identity Employment Authorization OR List B AND List CAdditional Information QR Code - Sections 2 & 3Do Not Write In This SpaceDocument TitleIssuing AuthorityDocument NumberExpiration Date (if any) (mm/dd/yyyy)Document TitleIssuing AuthorityDocument NumberExpiration Date (if any) (mm/dd/yyyy)Document TitleIssuing AuthorityDocument NumberExpiration Date (if any) (mm/dd/yyyy)Document TitleIssuing AuthorityDocument NumberExpiration Date (if any) (mm/dd/yyyy)Document TitleIssuing AuthorityDocument NumberExpiration Date (if any) (mm/dd/yyyy)Certification: I attest, under penalty of perjury, that (1) I 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/dd/yyyy) Title of Employer or Authorized Representative Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial B. Date of Rehire (if applicable)Date (mm/dd/yyyy)Document Title Document Number Expiration Date (if any) (mm/dd/yyyy) C. 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. 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 document(s) 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 Gillespie Kevin D 1N/A Driver's license Social Security Card (Unrestricted) N/A New Jersey DIVISION OF MOTOR VEHICLES Social Security Administration N/A 09281963 151-66-0181N/A 09/28/2032 N/AN/AN/AN/AN/AN/AN/AN/AN/ALISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIREDEmployees may present one selection from List Aor a combination of one selection from List B and one selection from List C. LIST A2. Permanent Resident Card or AlienRegistration Receipt Card (Form I-551)1. U.S. Passport or U.S. Passport Card3. Foreign passport that contains atemporary I-551 stamp or temporaryI-551 printed notation on a machine-readable immigrant visa4. Employment Authorization Documentthat contains a photograph (FormI-766)5. For a nonimmigrant alien authorizedto work for a specific employerbecause of his or her status:Documents that EstablishBoth Identity andEmployment Authorization6. Passport from the Federated Statesof Micronesia (FSM) or the Republicof the Marshall Islands (RMI) withForm I-94 or Form I-94A indicatingnonimmigrant admission under theCompact of Free Association Betweenthe United States and the FSM or RMIb. Form I-94 or Form I-94A that hasthe following:(1) The same name as the passport;and(2) An endorsement of the alien'snonimmigrant status as long asthat period of endorsement hasnot yet expired and theproposed employment is not inconflict with any restrictions orlimitations identified on the form.a. Foreign passport; andFor persons under age 18 who areunable to present a documentlisted above:1. Driver's license or ID card issued by aState or outlying possession of theUnited States provided it contains aphotograph or information such asname, date of birth, gender, height, eyecolor, and address9. Driver's license issued by a Canadiangovernment authority3. School ID card with a photograph6. Military dependent's ID card7. U.S. Coast Guard Merchant MarinerCard8. Native American tribal document10. School record or report card11. Clinic, doctor, or hospital record12. Day-care or nursery school record2. ID card issued by federal, state or localgovernment agencies or entities,provided it contains a photograph orinformation such as name, date of birth,gender, height, eye color, and address4. Voter's registration card5. U.S. Military card or draft recordDocuments that EstablishIdentityLIST BOR ANDLIST C7. Employment authorizationdocument issued by theDepartment of Homeland Security1. A Social Security Account Numbercard, unless the card includes one ofthe following restrictions:2. Certification of report of birth issuedby the Department of State (FormsDS-1350, FS-545, FS-240)3. Original or certified copy of birthcertificate issued by a State,county, municipal authority, orterritory of the United Statesbearing an official seal4. Native American tribal document6. Identification Card for Use ofResident Citizen in the UnitedStates (Form I-179)Documents that EstablishEmployment Authorization5. U.S. Citizen ID Card (Form I-197)(2) VALID FOR WORK ONLY WITHINS AUTHORIZATION(3) VALID FOR WORK ONLY WITHDHS AUTHORIZATION(1) NOT VALID FOR EMPLOYMENTForm I-9 10/21/2019 Page 3 of 3Examples of many of these documents appear in the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts.