Employment Eligibility Verification

Section 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. You must 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 "Lists of Acceptable Documents.")
Employee Info from Section 1
Name:

First Name (Given Name)Last Name (Family Name)
M.I.
Citizenship/Immigration Status:
List A Identity and Employment Authorization
Document Title:
Issuing Authority:
Document Number:
Expiration Date (if any):

MonthDayYear
Date
Document Title:
Issuing Authority:
Document Number:
Expiration Date (if any):

MonthDayYear
Date
Document Title:
Issuing Authority:
Document Number:
Expiration Date (if any):

MonthDayYear
Date
List B Identity
Document Title:
Issuing Authority:
Document Number:
Expiration Date (if any):

MonthDayYear
Date
AND
List C Employment Authorization
Document Title:
Issuing Authority:
Document Number:
Expiration Date (if any):

MonthDayYear
Date
Additional Information:
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:

Clear
Today's Date:

MonthDayYear
Date
Name:

First Name of Employer or Authorized RepLast Name of Employer or Authorized Representative
Title of Employer or auth Representative:
Employer's Business or Organization Name:
Address:

Employer's Business or Organization Address (Street Number and Name)

Street Address Line 2

City or TownState

ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative)
A New Name (if applicable):

First Name (Given Name)Middle InitialLast Name (Family Name)
B. Date of Rehire (if applicable):

MonthDayYear
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 provided below.
Document Title:
Document Number:
Expiration Date (if any):

MonthDayYear
Date
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
Signature:

Clear
Today's Date:

MonthDayYear
Date
Name of Employer or Authorized Representative:

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.
Refer to the instructions for more information about acceptable receipts.
Should be Empty:

Section 1. Employee Information and Attestation

Preparer and/or Translator Certification:

Employee Info from Section 1

List A Identity and Employment Authorization

List B Identity

AND

List C Employment Authorization

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative)