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Employment Eligibility Verification USCIS Department of Homeland Security Form I-9 OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 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) anemployee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because thedocumentation 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 laterthan 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 CodeDate of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number - -I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents inconnection with the completion of this form
I attest, under penalty of perjury, that I am (check one of the following boxes): 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident (Alien Registration Number/USCIS Number): 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) QR Code - Section 1 Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: Do Not Write In This Space An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number
1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance:Signature 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 myknowledge 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 PageForm I-9 10/21/2019 Page 1 of 3 Employment Eligibility Verification USCIS Department of Homeland Security Form I-9 OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 10/31/2022Section 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. Youmust 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 "Listsof Acceptable Documents.") Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration StatusEmployee Info from Section 1 List A OR List B AND List C Identity and Employment Authorization Identity Employment AuthorizationDocument Title Document Title Document TitleIssuing Authority Issuing Authority Issuing AuthorityDocument Number Document Number Document NumberExpiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy)Document Title QR Code - Sections 2 & 3Issuing Authority Additional Information Do Not Write In This SpaceDocument 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 theemployee 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 RepresentativeLast Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name University of Central ArkansasEmployer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code201 Donaghey Avenue Conway AR 72035Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable) B. Date of Rehire (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishescontinuing employment authorization in the space provided below
Document Title Document Number 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 ifthe 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 RepresentativeForm I-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
LIST A LIST B LIST C Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization Employment Authorization OR AND1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number State or outlying possession of the card, unless the card includes one of2. Permanent Resident Card or Alien United States provided it contains a the following restrictions: Registration Receipt Card (Form I-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT name, date of birth, gender, height, eye3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH temporary I-551 stamp or temporary INS AUTHORIZATION I-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION provided it contains a photograph or4. Employment Authorization Document information such as name, date of birth, 2. Certification of report of birth issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Forms I-766) DS-1350, FS-545, FS-240) 3. School ID card with a photograph5. For a nonimmigrant alien authorized 3. Original or certified copy of birth to work for a specific employer 4. Voter's registration card certificate issued by a State, because of his or her status: county, municipal authority, or 5. U.S. Military card or draft record territory of the United States a. Foreign passport; and 6. Military dependent's ID card bearing an official seal b. Form I-94 or Form I-94A that has the following: 7. U.S. Coast Guard Merchant Mariner 4. Native American tribal document (1) The same name as the passport; Card 5. U.S. Citizen ID Card (Form I-197) and 8. Native American tribal document (2) An endorsement of the alien's 6. Identification Card for Use of nonimmigrant status as long as 9. Driver's license issued by a Canadian Resident Citizen in the United that period of endorsement has government authority States (Form I-179) not yet expired and the proposed employment is not in For persons under age 18 who are 7. Employment authorization conflict with any restrictions or unable to present a document document issued by the limitations identified on the form. Department of Homeland Security listed above:6. Passport from the Federated States 10. School record or report card of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with 11. Clinic, doctor, or hospital record Form I-94 or Form I-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RMI 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 I-9 10/21/2019 Page 3 of 3
Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services Form I-9 10/21/2019 Page 1 …
I-9, Employment Eligibility Verification Use Form I-9 to verify the identity and employment authorization of individuals hired for employment in the United States. All U.S. employers must properly complete Form I-9 for each individual they hire for employment in the United States. This includes citizens and noncitizens.
The Spanish version of Form I-9 may be filled out by employers and employees in Puerto Rico ONLY. Spanish-speaking employers and employees in the 50 states and other U.S. territories may print this for their reference, but may only complete the form in English to meet employment eligibility verification requirements.
The Department of Homeland Security does not require the authorized representative to have specific agreements or other documentation for Form I-9 purposes. If an authorized representative fills out Form I-9 on behalf on the employer, the employer is still liable for any violations in connection with the form or the verification process.
Form I-9 must be retained and stored by the employer either for three years after the date of hire or for one year after employment is terminated, whichever is later. The form must be available for inspection by authorized U.S. Government officials from the Department of Homeland Security,...