One Heart - I 9 Form - Employment Eligibility Verification

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-9
OMB No. 1615-0047

►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) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation 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 later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)*
Full Name *

First Name (Given Name)Middle InitialOther Last Names Used (if any)
Address*
(Street Number and Name)
Apt. Number
City or Town*
State*
ZIP Code*
Date of Birth*

MonthDayYear
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 in connection 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 States2. A noncitizen national of the United States (See instructions)3. A lawful permanent resident4. An alien authorized to work until
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)
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
- An Alien Registration Number/USCIS Number
- OR Form I-94 Admission Number
- OR Foreign Passport Number.
Alien Registration Number/USCIS Number
Form I 94 Admission Number
Foreign Passport Number
Country of Issuance
Signature of Employee*
Today's Date*

MonthDayYear
Date
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.
Signature of Preparer or Translator
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Address

Address

Street Address Line 2

City or TownState

ZIP Code
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.")
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

MonthDayYear
Date
Document Title
Issuing Authority
Document Number
Expiration Date

MonthDayYear
Date
List B

Identity
Document Title
Issuing Authority
Document Number
Expiration Date

MonthDayYear
Date
List C

Employment Authorization
Document Title
Issuing Authority
Document Number
Expiration Date

MonthDayYear
Date
Additional Information
Signature of Employer or Authorized Representative
Today's Date

MonthDayYear
Date
Title of Employer or Authorized Representative
Name of Employer or Authorized Representative

First NameLast Name
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
Zip Code
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

MonthDayYear
Date
LISTS OF ACCEPTABLE DOCUMENTS

All documents must be UNEXPIRED
For verification purpose, please submit any two of the following documents:
- Green Card
- Social Security
- H1B Visa
- Passport
- Driver's License
- Birth Certificate
Please attached scanned copy/picture of any two of documents listed above.

Browse Files
File Type: pdf, doc, docx, jpg, jpeg, png, gif Max Size: 5 MB Cancelof
Should be Empty:

Section 1. Employee Information and Attestation

Section 2. Employer or Authorized Representative Review and Verification

List A

List B

List C

LISTS OF ACCEPTABLE DOCUMENTS