11-25-13 Common Council Agenda & Packet

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Employment Eligibility Verification USCIS Form 1-9 oUF Department of Homeland Security `4ND Sffp OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 03/31/2016 ►START HERE. Read instructions carefully before completing this form.The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals.Employers CANNOT specify which document(s)they will accept from an employee. The refusal to hire 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 1-9 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 Other Names Used(if any) Address(Street Number and Name) Apt. or Town State Zip Code Date of Birth(mm/dd/yyyy) U.S.Social Security Number E-mail Address 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. 1 attest,under penalty of perjury,that I am(check one of the following): ❑ A citizen of the United States ❑ A noncitizen national of the United States (See instructions) ❑ A 'awful permanent resident(Alien Registration Number/USCIS Number): ❑ An alien authorized to work until(expiration date, if applicable,mm/dd/yyyy) .Some aliens may write"N/A"in this field. (See instructions) For aliens authorized to work,provide your Alien Registration Number'USCIS Number OR Form 1-94 Admission Number: 1.Alien Registration Number/USCIS Number: OR 3-D Barcode Do Not Write in This Space 2. Form 1-94 Admission Number: If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: Country of Issuance: Some aliens may write"N/A"on the Foreign Passport Number and Country of Issuance fields. (See instructions) Signature of Employee: Date(mm/dd/yyyy): Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest,under penalty of perjury,that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator: Date(mm/dd/yyyy): Last Name(Family Name) First Name(Given Name) Address(Street Number and Name) City or Town State Zip Code Employer Completes Next Page Form 1-9 03/08/13 N Page 7of9