Apply Job

Section 1: Employee Information and Attestation

Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used
Street Address
Apt. Number
City or Town
State
ZIP Code
Date of Birth (MM/DD/YYYY)
U.S. Social Security Number
Email
Phone

Citizenship or Immigration Status

U.S. CitizenNoncitizen NationalLawful Permanent ResidentAuthorized to Work

If you selected #3 (Lawful Permanent Resident)

USCIS or A-Number

If you selected #4 (Authorized to Work)

Authorized to Work Until
USCIS A-Number
Form I-94 Admission Number
Foreign Passport Number
Country of Issuance

Signature of Employee
Today's Date

Supplement A: Preparer and/or Translator Certification

Was a preparer/translator used?
YesNo

If yes, complete the following:

Preparer/Translator Last Name
First Name
Middle Initial
Street Address
City or Town
State
ZIP Code
Signature
Date

Section 2: Employer Review and Verification

Document Title (List A)
Issuing Authority
Document Number
Expiration Date

OR

Document Title (List B)
Issuing Authority
Document Number
Expiration Date

Document Title (List C)
Issuing Authority
Document Number
Expiration Date

Used DHS alternative procedure to examine documents?Yes

Additional Information

First Day of Employment

Employer/Representative Full Name
Title
Signature
Date
Business/Organization Name
Business Address
City
State
ZIP Code

Supplement B: Reverification and Rehire

Employee Last Name
First Name
Middle Initial

New Legal Name (if applicable)
Date of Rehire (if applicable)

Reverification: Provide new documentation

Document Title
Document Number
Expiration Date

Employer Name
Signature of Employer
Today's Date

Used DHS alternative procedure?Yes
Additional Notes