U.S. Department of Justice
Immigration and Naturalization Service
OMB No. 1115-0136
Employment Eligibility Verification
Please read Instructions carefully before completing this form. The instructions must be available during completion of
this form. ANTI-DISCRIMINATION NOTICE. It is illegal to discriminate against work eligible individuals. Employers CAN-
NOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future
expiration date may also constitute Illegal discrimination.
.
Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins
I am aware that federal law provides for impris-
onment and/or fines for false statements of 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):
A citizen or national of the United States
A Lawful Permanent Resident (Alien # A
)
An alien authorized to work until
/
/
(Alien # or Admission #
)
Employee's Date (monlWaylyear)
Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a person
other than the employee.) I attest, under penalty of perjury, that / have assisted in the completion of this form and
that to the best of my knowledge the information is true and correct.
Print Name
Preparer's/Translator's Signature
Address (Street Name and Number, ON State, Zip Code)
Section 2. Employer Review and verification. To be completed and signed by employer. Examine one document from List A OR
examine one document from List B and one from List C as listed on the reverse of this form and record the title, number and expiration date, if any, of the
document(s).
List B
OR
AND
List C
List A
Document title*
Issuing Authority:
Document #,
Expiration Date (it any):
/
/
Document #-
Expiration