Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USC1S Form 1-9 OMB No. 1615-0047 Expires 08/31/2019

Section 2 Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business day of the employees first day of employment. You must physically examine one document form List A or a combination of one document from B and one document from C as listed on the Lists of Acceptable Documents).

Employee Info from Section 1

Last Name (Family Name)
First Name (Given Name)
M.I.
Citizenship/ Immigration Status

Complete the list A or complete list B and C

List A

Identity and Employment Authorization

Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/ yyyy)

Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)

Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)

List B

Identity

Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)

List C

Employment Authorization

Document Title
Issuing Authority
Document Number
Expiration 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
Employers 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)

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 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 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