Employment Authorization Card Receipt Acknowledgement Form
Please complete this form to acknowledge receipt of your employment authorization card. Do not enter any sensitive personal or financial information.
Employee Full Name
*
First Name
Last Name
Employee Work Email
*
example@example.com
Department
*
Please Select
Human Resources
Finance
Operations
IT
Legal
Sales
Marketing
Other
Job Title
*
Supervisor Name
*
Date Card Received
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Employment Authorization Card
*
Please Select
Temporary Employment Authorization
Permanent Resident Card
Work Permit
Other
Last 4 Digits of Card Number
*
Card Issuing Authority
*
Please Select
U.S. Citizenship and Immigration Services (USCIS)
Department of Homeland Security
Other
Employee Signature
*
Submit Acknowledgement
Submit Acknowledgement
Should be Empty: