I9 SAMPLE - US PASSPORT
1 - 17 Must be completed by Employee
Employment Eligibility Verification USCIS
Department of Homeland Security Form I-9
OMB No. 1615-0047
U.S. Citizenship and Immigration Services Expires 08/31/2019
ŹSTART HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ
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 I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) 1 First Name (Given Name) 2 Middle Initial 3 Other Last Names Used (if any) 4
Traveler Happy N/A
Address (Street Number and Name) 5 Apt. Number 6 City or Town
7 State 8 ZIP Code 9
134 MAIN STREET N/A ANY TOWN CA 95134
Date of Birth (mm/dd/yyyy)
10 U.S. Social Security Number 11 Employee's E-mail Address 12 Employee's Telephone Number
13
07/04/1967 123 - 45 - 6 7 8 9 [email protected] 999-123-4567
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.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States 14
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field. (See instructions)
QR Code - Section 1
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: Do Not Write In This Space
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
OR
2. Form I-94 Admission Number:
OR
3. Foreign Passport Number:
Country of Issuance:
Signature of Employee Today's Date (mm/dd/yyyy)
15 16 11/19/2016
17 Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator Today's 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 I-9 11/14/2016 N 5 of 22
18 - 27 Must be completed by person inspecting original documents
Employment Eligibility Verification USCIS
Department of Homeland Security Form I-9
OMB No. 1615-0047
U.S. Citizenship and Immigration Services Expires 08/31/2019
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 a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status
Employee Info from Section 1
Traveler Happy A citizen of the United States
List A OR List B AND List C
Identity and Employment Authorization Identity Employment Authorization
Document Title 18 Document Title Document Title
USA Passport
Issuing Authority 19 Issuing Authority Issuing Authority
USA
Document Number 20 Document Number Document Number
34007237
Expiration Date (if any)(mm/dd/yyyy) 21 Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy)
08/07/2020
Document Title
QR Code - Sections 2 & 3
Issuing Authority Additional Information Do Not Write In This Space
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) 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.
22
The employee's first day of employment (mm/dd/yyyy): 11/18/2016 (See instructions for exemptions)
Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative
23 24
04/22/2013 Representative/friend 25
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Contreras 26 Sergio 27 $*4$04:45&.4
Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
85"4."/%3*7& $PSQ)FBERVBSUFST 4"/+04& $"
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) B. Date of Rehire (if applicable)
Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
Document Title Document Number Expiration Date (if any) (mm/dd/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 document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
Form I-9 11/14/2016 N 6 of 22
