Masonry Magazine August 1987 Page. 33
EMPLOYMENT ELIGIBILITY VERIFICATION (Form 1-9)
1 EMPLOYEE INFORMATION AND VERIFICATION: (To be completed and signed by employee.)
Name: (Print or Type) Last First Middle Birth Name
Address: Street Name and Number City State ZIP Code
Date of Birth (Month/Day/Year) Social Security Number
I attest, under penalty of perjury, that I am (check a box):
1. A citizen or national of the United States.
2. An alien lawfully admitted for permanent residence (Alien Number A ).
3. An alien authorized by the Immigration and Naturalization Service to work in the United States (Alien Number A or Admission Number expiration of employment authorization, if any ).
I attest, under penalty of perjury, the documents that I have presented as evidence of identity and employment eligibility are genuine and relate to me. I am aware that federal law provides for imprisonment and/or fine for any false statements or use of false documents in connection with this certificate.
Signature
Date (Month/Day/Year)
PREPARER/TRANSLATOR CERTIFICATION (To be completed if prepared by person other than the employee). I attest, under penalty of perjury, that the above was prepared by me at the request of the named individual and is based on all information of which I have any knowledge.
Signature
Name (Print or Type)
Address (Street Name and Number) City State Zip Code
2 EMPLOYER REVIEW AND VERIFICATION: (To be completed and signed by employer.)
Instructions: Examine one document from List A and check the appropriate box, OR examine one document from List B and one from List C and check the appropriate boxes. Provide the Document Identification Number and Expiration Date for the document checked.
List A
Documents that Establish
Identity and Employment Eligibility
List B
Documents that Establish
Identity
List C
and
Documents that Establish
Employment Eligibility
1. United States Passport
2. Certificate of United States Citizenship
3. Certificate of Naturalization
4. Unexpired foreign passport with attached Employment Authorization
5. Alien Registration Card with photograph
Document Identification #
Expiration Date (if any)
1. A State-issued driver's license or a State-issued I.D. card with a photograph, or information, including name, sex, date of birth, height, weight, and color of eyes. (Specify State).
2. U.S. Military Card
3. Other (Specify document and issuing authority)
Document Identification #
Expiration Date (if any)
1. Original Social Security Number Card (other than a card stating it is not valid for employment)
2. A birth certificate issued by State, county, or municipal authority bearing a scal or other certification
3. Unexpired INS Employment Authorization
Specify form #
Document Identification #
Expiration Date (if any)
CERTIFICATION: I attest, under penalty of perjury, that I have examined the documents presented by the above individual, that they appear to be genuine and to relate to the individual named, and that the individual, to the best of my knowledge, is eligible to work in the United States.
Signature
Name (Print or Type)
Title
Employer Name
Address
Date
Form 1-9 (05/07/87)
OMB No. 1115-0136
U.S. Department of Justice
Immigration and Naturalization Service
MASONRY-JULY/AUGUST, 1987 33