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Employment Eligibility Verification USCIS o�x Department of Homeland Security Form I-9 De jj t7' OMB No. 1615-Oi)47 1,Yn 54G U.S. Citizenship and Immigration Services Expires 07/3112026 START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form, See below and the Instructions. ANTI -DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form 1-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Sunnlement B. Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal. 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) \ien Middle Initial (if any Other Last Names Used (if any) Address (Street Number nd Name) vv . 1[-:a 1 r�t. Apt. Number (if any) Cit or Town e� Po; State � ZtP Code I q k 3 Date of Binh (mm/ddfyyy } U.S. Social Security Number f 2 71 Cf t-) iv Employee's Email Address irri t j4 QTiY1414 Employee's Telephone Number 7 Lit 3, z+✓i 1 am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration Status, is true and correct. Chec no of the following boxes Co attest to your citizenship or immigration status (See page 2 and 3 of the instructions.): 1. A citizen of the United States ❑ 2. A noncitizen national of the United States (See Instructions.) 3. A lawful permanent resident (Enter USCIS or A -Number.) ❑ 4. A noncitizen (other than hem Numbers 2. and 3. above) authorized to work until (exp. date, if any) If you check Item Number 4., enter one of these. USCIS A -Number oe Form I-94 Admission Number olz Foreign Passport Number and Country of Issuance Signature of Employee Tcday's Date (mmldd/yyyy) If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3. Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box, see Instructions. List A OR List B AND List C Document Title tf)f CL Issuing Authority t Document Number (if any) -� - ti - Expiration Date (if any) Document Title 2111 any/ Additional Information Check here if you used an afternative procedure authorized by DHS to examine documents. Issuing Authority Document Number (if any) Expiration Dale (if any) Document Title 3 (if anyl Issuing Authority Document Number (if any) Expiration Date (f an Certification: I attest, under penalty of perjury, that (1)1 have examined the documentation presented by the above -named employee, (2) the above -listed documentation appears to be genuine and to relate to the employee named, and 13) to the best of my knowledge, the employee is authorized to work in the United States. First Day of Employment (mm/ddlyyyy): Last Name, First Name and Title of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mnVddlyyyy) Employer's Business or Organization Name Employers Business or Organization Address, City or Town, State, ZIP Code For reverificatlon or rehire, complete Supplement,13Reverifleat(on and Rehire on Page 4. Form 1-9 Edition 08/01/23 Page I of