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Click here or scroll down to respond to this candidateEmployment Eligibility VerificationDepartment of Homeland SecurityU.S. Citizenship and Immigration ServicesUSCISForm I-9OMB No.Street Address -0047Expires 07/31/2026START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions. ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal. 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 (if any) Other Last Names Used (if any) Address (Street Number and Name) Apt. Number (if any) City or Town State ZIP Code Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's Email Address Employee's Telephone Number I am aware that federal lawprovides for imprisonment and/orfines for false statements, or theuse of false documents, inconnection with the completion ofthis form. I attest, under penaltyof perjury, that this information,including my selection of the boxattesting to my citizenship orimmigration status, is true andcorrect.Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.): 1. A citizen of the United States2. A noncitizen national of the United States (See Instructions.) 3. A lawful permanent resident (Enter USCIS or A-Number.) 4. A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any) If you check Item Number 4., enter one of these:USCIS A-NumberORForm I-94 Admission NumberORForeign Passport Number and Country of IssuanceSignature of Employee Today's Date (mm/dd/yyyy)If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3. Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions. List A OR List B AND List CDocument Title 1Issuing AuthorityDocument Number (if any)Expiration Date (if any)Document Title 2 (if any) Additional InformationIssuing AuthorityCheck here if you used an alternative procedure authorized by DHS to examine documents. Document Number (if any)Expiration Date (if any)Document Title 3 (if any)Issuing AuthorityDocument Number (if any)Expiration Date (if any)Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears 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. First Day of Employment(mm/dd/yyyy):Last Name, First Name and Title of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Employer's Business or Organization Name Employer's Business or Organization Address, City or Town, State, ZIP Code For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4. Form I-9 Edition 08/01/23 Page 1 of 4Smith Zaire S1108 Jacob street Durham NC 2770108/10/PHONE NUMBER AVAILABLE 7 EMAIL AVAILABLE PHONE NUMBER AVAILABLE 4Zaire smith 02/20/2024LISTS OF ACCEPTABLE DOCUMENTSAll documents containing an expiration date must be unexpired.* Documents extended by the issuing authority are considered unexpired. Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. Examples of many of these documents appear in the Handbook for Employers (M-274). LIST ADocuments that Establish Both Identityand Employment Authorization ORLIST BDocuments that Establish IdentityLIST CDocuments that Establish EmploymentAND Authorization1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a State or outlying possession of the United Statesprovided it contains a photograph orinformation such as name, date of birth,gender, height, eye color, and address1. A Social Security Account Number card,unless the card includes one of the followingrestrictions:(1) NOT VALID FOR EMPLOYMENT(2) VALID FOR WORK ONLY WITHINS AUTHORIZATION(3) VALID FOR WORK ONLY WITHDHS AUTHORIZATION2. Permanent Resident Card or AlienRegistration Receipt Card (Form I-551)3. Foreign passport that contains atemporary I-551 stamp or temporaryI-551 printed notation on a machine-readable immigrant visa2. ID card issued by federal, state or localgovernment agencies or entities, provided itcontains a photograph or information such asname, date of birth, gender, height, eye color,and address4. Employment Authorization Documentthat contains a photograph (Form I-766) 2. Certification of report of birth issued by the Department of State (Forms DS-1350,FS-545, FS-240)5. For an individual temporarily authorized 3. School ID card with a photograph to work for a specific employer becauseof his or her status or parole:a. Foreign passport; andb. Form I-94 or Form I-94A that hasthe following:(1) The same name as thepassport; and(2) An endorsement of theindividual's status or parole aslong as that period ofendorsement has not yetexpired and the proposedemployment is not in conflictwith any restrictions orlimitations identified on the form.4. Voter's registration card 3. Original or certified copy of birth certificate issued by a State, county, municipalauthority, or territory of the United Statesbearing an official seal5. U.S. Military card or draft record6. Military dependent's ID card4. Native American tribal document7. U.S. Coast Guard Merchant Mariner Card5. U.S. Citizen ID Card (Form I-197)8. Native American tribal document6. Identification Card for Use of Resident9. Driver's license issued by a Canadian Citizen in the United States (Form I-179) government authority7. Employment authorization documentissued by the Department of HomelandSecurityFor examples, see Section 7 andSection 13 of the M-274 onuscis.gov/i-9-central.The Form I-766, EmploymentAuthorization Document, is a List A, ItemNumber 4. document, not a List Cdocument.For persons under age 18 who areunable to present a documentlisted above:10. School record or report card6. Passport from the Federated States ofMicronesia (FSM) or the Republic of theMarshall Islands (RMI) with Form I-94 orForm I-94A indicating nonimmigrantadmission under the Compact of FreeAssociation Between the United Statesand the FSM or RMI11. Clinic, doctor, or hospital record12. Day-care or nursery school recordAcceptable ReceiptsMay be presented in lieu of a document listed above for a temporary period. For receipt validity dates, see the M-274. Receipt for a replacement of a lost,stolen, or damaged List A document. Form I-94 issued to a lawfulpermanent resident that contains anI-551 stamp and a photograph of theindividual. Form I-94 with RE notation orrefugee stamp issued to a refugee.ORReceipt for a replacement of a lost, stolen, ordamaged List B document.Receipt for a replacement of a lost, stolen, ordamaged List C document.*Refer to the Employment Authorization Extensions page on I-9 Central for more information. Form I-9 Edition 08/01/23 Page 2 of 4Supplement A,Preparer and/or Translator Certification for Section 1 Department of Homeland SecurityU.S. Citizenship and Immigration ServicesUSCISForm I-9Supplement AOMB No. 1615-0047Expires 07/31/2026Last Name (Family Name) from Section 1. First Name (Given Name) from Section 1. Middle initial (if any) from Section 1. Instructions: This supplement must be completed by any preparer and/or translator who assists an employee in completing Section 1 of Form I-9. The preparer and/or translator must enter the employee's name in the spaces provided above. Each preparer or translator must complete, sign, and date a separate certification area. Employers must retain completed supplement sheets with the employee's completed Form I-9.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 Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial (if any) Address (Street Number and Name) City or Town State ZIP Code 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 Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial (if any) Address (Street Number and Name) City or Town State ZIP Code 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 Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial (if any) Address (Street Number and Name) City or Town State ZIP Code 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 Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial (if any) Address (Street Number and Name) City or Town State ZIP Code Form I-9 Edition 08/01/23 Page 3 of 4Supplement B,Reverification and Rehire (formerly Section 3)USCISForm I-9Supplement BOMB No. 1615-0047Expires 07/31/2026Department of Homeland SecurityU.S. Citizenship and Immigration ServicesLast Name (Family Name) from Section 1. First Name (Given Name) from Section 1. Middle initial (if any) from Section 1. Instructions: This supplement replaces Section 3 on the previous version of Form I-9. Only use this page if your employee requires reverification, is rehired within three years of the date the original Form I-9 was completed, or provides proof of a legal name change. Enter the employee's name in the fields above. Use a new section for each reverification or rehire. Review the Form I-9 instructions before completing this page. Keep this page as part of the employee's Form I-9 record. Additional guidance can be found in the Handbook for Employers: Guidance for Completing Form I-9 (M-274) Date of Rehire (if applicable) New Name (if applicable) Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below. Document Title Document Number (if any) Expiration Date (if any) (mm/dd/yyyy) 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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it. Name of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Additional Information (Initial and date each notation.) Check here if you used an alternative procedure authorizedby DHS to examine documents.Date of Rehire (if applicable) New Name (if applicable) Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below. Document Title Document Number (if any) Expiration Date (if any) (mm/dd/yyyy) 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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it. Name of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Additional Information (Initial and date each notation.) Check here if you used an alternative procedure authorizedby DHS to examine documents.Date of Rehire (if applicable) New Name (if applicable) Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below. Document Title Document Number (if any) Expiration Date (if any) (mm/dd/yyyy) 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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it. Name of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Additional Information (Initial and date each notation.) Check here if you used an alternative procedure authorizedby DHS to examine documents.Form I-9 Edition 08/01/23 Page 4 of 4 |
