Employee Application I-9 | Brazos Masonry

Employee Application - Form I-9

Employment Eligibility Verification - USCIS Form I-9

Department of Homeland Security
U.S. Citizenship and Immigration Services

START 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

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.

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 States

2 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

Enter USCIS or A-Number

(exp. date, if any)

If you check Item Number 4., enter one of these:

USCIS A-Number

(OR) Form I-94 Admission Number

(OR) Foreign Passport Number and Country of Issuance

Signature of Employee

Clear

Today’s Date

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

Document Title 1

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 2 (if any)

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 3 (if any)

Issuing Authority

Document Number (if any)

Expiration Date (if any)

(or) LIST B

Document Title

Issuing Authority

Document Number (if any)

Expiration Date (if any)

(and) LIST C

Document Title

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Additional Information

Alt Procedure

Check here if you used an alternative procedure authorized by DHS to examine documents

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

First Day of Employment

Last Name, First Name of Employer or Authorized Representative

Title of Employer or Authorized Representative

Signature of Employer or Authorized Representative

Clear

Today’s Date

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.

LISTS OF ACCEPTABLE DOCUMENTS

All 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 A (Documents that Establish Both Identity and Employment Authorization)
1. U.S. Passport of U.S. Passport Card
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For an individual temporarily authorized to work for a specific employer because of his or her status or parole: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

Acceptable Receipts (May 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 lawful permanent resident that contains an I-551 stamp and a photograph of the individual.
Form I-94 with “RE” notation or refugee stamp issued to a refugee.

LIST B (Documents that Establish Identity)	AND - LIST C (Documents that Establish Employment Authorization)
1. Driver's license or ID card issued by a 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	1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
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	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	3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
4. Voter's registration card	4. Native American tribal document
5. U.S. Military card or draft record	5. U.S. Citizen ID Card (Form I-197)
6. Military dependent's ID card	6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
7. U.S. Coast Guard Merchant Mariner Card	7. Employment authorization document issued by the Department of Homeland Security For examples, see Section 7 and Section 13 of the M-274 on uscis.gov/i-9-central. The Form I-766, Employment Authorization Document, is a List A, Item Number 4. document, not a List C document.
8. Native American tribal document
9. Driver's license issued by a Canadian government authority
For persons under age 18 who are unable to present a document listed above:
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record

Acceptable Receipts (May 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 B document.	Receipt for a replacement of a lost, stolen, or damaged List C document.

° Refer to the Employment Authorization Extensions page on I-9 Central for more information.

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