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Section 2 Employer or Authorized Rep�esentative`Review'iirid .yenfiCation <br />Employee Last Name, First Name and Middle Initial from Section 1: <br />List A OR List B AND List C <br />^ Identity and Employment Authorization Identity _ Employment Authorization <br />Number: <br />Expiration Date (ifany)(mm/dd/yyyy): <br />Number: <br />Title: <br />Number: <br />Document Number: <br />Expiration Date (if any)(mm/dd/yyyy): <br />3 -D Barcode <br />Do Not Write in This Space <br />Certification <br />I attest, under penalty of perjury, that (1) 1 have examined the document(s) presented by the above -named employee, (2) the <br />above - listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the <br />employee is authorized to work in the United States. <br />The employee's first day of employment (mmfdd/yyyy): (See instructions for exemptions.) <br />Signature of Employer or Authorized Representative Date (mm/dd/yyyy) I Title of Employer or Authorized Representative <br />Last Name (Family Name) First Name (Given Name) Employers Business or Organization Name <br />Employer's Business or Organization Address (Street Number and Name) City or Town State Zip Code <br />Section 3-, Reverification and Rehires (To be completed and signed by employer or authorized representative.) <br />A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initi al B. Date of Rehire (d applicable) I'mm/dd/yyyy): <br />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 <br />presented that establishes current employment authorization in the space provided below. <br />Document Title: Document Number: Expiration Date (if any)(mm/dd/yyyy): <br />I attest, under penalty of perjury, that to the best of my knowledge, this employee Is authorized to work in the United States, and it <br />the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the InAh ielrrnl <br />Signature of Employer or Authorized Representative: Date (mm/dd/yyyy): Print Name of Employer or Authorized Representative: <br />Form I -9 03/08/13 N Page 9 of 9 <br />