11-25-13 Common Council Agenda & Packet

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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 examine a combination of one document.from List B and one document from List C as listed on the "Lists of Acceptable Documents"on the next page of this form.For each document you review,record the following information:document title, issuing authority,document number,and expiration date,if any.) Employee Last Name,First Name and Middle Initial from Section 1: List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization Document Title: Document Title: Document Title: Issuing Authority: Issuing Authority: Issuing Authority: Document Number: n.Document Number: Document Number: a k Expiration Date(if any)(mmyddyyyyy). a Expiration Date(if any)(mmyddlyyyy): Expiration Date(if any)(mm/dd/yyyy): Document Title: Issuing Authority: Document Number: Expiration Date(if any)(mm/ddyyyyy): 3-D Barcode Document Title: Do Not Write in This Space Issuing Authority: Document Number Expiration Date(if any)(mm/ddyyyyy): Certification I attest, under penalty of perjury,that(1) 1 have examined the document(s)presented by the above-named employee,(2)the above-listed documents)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 of Employer or Authorized Representative Date(mm/dd/yyyy) Title of Employer or Authorized Representative Last Name(Family Name) First Name(Given Name) Employer's Business of Organization Name Employer's Business or Organization Address(Street Number and Name) City or Town State Zip Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A.New Name(if applicable)Las(Name(Family Name) First Name(Given Name) Middle Initial B.Date of Rehire(if applicable)(M Y) C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below. Document Title. Document Number. Expiration Date(tfany)(mMdtl/yyyy): 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 documents)I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative. Date(mm/dd/yyyy): Print Name of Employer or Authorized Representative: Form 1-9 03708/13 N Page 8 of