Skip to content
(713) 248-5866
[email protected]
Facebook-f
Linkedin-in
Google
Home
About
Services
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Therapy
Home Health Aide Services
Medical Social Services
COPD Education
Wound and Ostomy Care
Long Term Care
Home Services
Residential Homes
Host Family Care Program
In-Home Support
Blog
Service Areas
Pre–Hire Forms
Prospective Clients
Contact
Menu
Home
About
Services
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Therapy
Home Health Aide Services
Medical Social Services
COPD Education
Wound and Ostomy Care
Long Term Care
Home Services
Residential Homes
Host Family Care Program
In-Home Support
Blog
Service Areas
Pre–Hire Forms
Prospective Clients
Contact
Schedule Consultation
Quick Inquiry
Employment Eligibility Verification
USCIS Form I-9
"
*
" indicates required fields
Department of Homeland Security
U.S. Citizenship and Immigration Services
START 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)
Name
*
First Name (Given Name)
Last Name (Family Name)
Middle Initial
Other Last Names Used (if any)
Address
*
Apt. Number
*
City or Town
*
State (Two-Letter Abbreviation)
*
ZIP Code
*
Date of Birth (mm/dd/yyyy)
*
MM slash DD slash YYYY
U.S. Social Security Number
*
Employee's E-mail Address
Employee's Telephone Number
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
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 (enter the expiry date below):
USCIS A-Number
Form I-94 Admission Number
Foreign Passport Number and Country of Issuance
Signature of Employee
*
Today's Date (mm/dd/yyyy)
MM slash DD slash YYYY
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
Document Title 1:
Issuing Authority:
Document Number (if any):
Expiration Date (if any):
Document Title 2:
Issuing Authority:
Document Number (if any):
Expiration Date (if any):
Document Title 3:
Issuing Authority:
Document Number (if any):
Expiration Date (if any):
OR
List B
Document Title 1:
Issuing Authority:
Document Number (if any):
Expiration Date (if any):
AND
List C
Document Title 1:
Issuing Authority:
Document Number (if any):
Expiration Date (if any):
Additional Information:
Check here if you used an alternative procedure authorized by DHS to examine documents.
*
Certification: I attest, under penalty of perjury, that (1) I 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 (3) to the best of my knowledge, the employee is authorized to work in the United States.
First Day of Employment (mm/dd/yyyy):
MM slash DD slash YYYY
Last Name, First Name and Title of Employer or Authorized Representative
Title
First Name (Given Name)
Last Name (Family Name)
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
MM slash DD slash YYYY
Employer's Business or Organization Name
Employer's Business or Organization Address
City or Town
State (Two-Letter Abbreviation)
ZIP Code
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
Schedule Appointment
"
*
" indicates required fields
Name
*
Email
*
Phone
*
Best Time to Call?
Morning
Afternoon
Evening
Message (optional)
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
