AND
Page 3 of3
first day of employment,
D
D
D
D
OR
OR
D
0
I
(m
G
Z
H
Employment
Eligibility Verification
Department
of Homeland Security
U.S. Citizenship and
Imrnigration
Services
USCIS
Form I-9
OMB
No.
l6l5-0047
Expies
l0/31/2022
Section
2. Employer or
Authorized
Representative Review and Verification
(Employers
or
their authoized representative must
complete and sign
Secfibn 2 within
3 busltess days of the employee's
first day of employment. You
must
physically
examine one document
frcm List A
OR a combination of one
document from List B
and one document from
L,sf
C
as /lsfed
on the
"Lists
of
Acce
ptable
D oc u me nts.')
Employee lnfo
from
Section 1
Last Name
(Family
Name)
First Name
(Given
Name)
M.t. Citizenship/lmmigration Status
ldentity
and
Employment Authorization
ldentity
Employment
Authorization
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)
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 Dale
(mm/dd/yyyy)
Name
of
Employer or Authorized Representative
Document Title
lssuing Authoriiy
Expiration Date
(if
any)
(mm/dd/yyyy)
Document Title
lssuing
Authority
Document Number
Expiration Dale
(if
any)
(mm/dd/yyyy)
Expiration
Date
any)
Document Title
lssuing Authority
Document Title
Document Number
Expiration Date
(if
any)
(mm/dd/yyyy)
Document Title
lssuing Authority
Expiration Dale
(if
any)
(mm/dd/yyyy)
Additional lnformation
QRCode-Sections2&3
Do Not Write ln This Space
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 ZIP Code
Section 3.
Reverification
and
Rehires
(To
be compteted 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 lnitial Date
(mm/dd/yyyy)
authorization in the space
provided
below.
document or
receipt
that establishes
the employee's
previous grant
Document Title Document
Number Expiration
Dale
(if
any)
(mn/dd/yyyy)
Forrn I-9 10121/2019
Page 2
of3
Authorized Representative
Bikini Atoll Rd. SM-30
Los Alamos
NM
87545
