Employment Eligibility Verification Form

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Number Address (Street Number and Name) Date of Birth (mm/dd/yyyy) Middle Initial First Name (Given Name) U.S. Social Security Number - Other Last Names Used (if any) State City or Town ZIP Code Employee s Telephone Number Employee s E-mail Address - 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.. First Name (Given Name) Last Name (Family Name) OR List B AND List C Identity Identity and Employment Authorization Citizenship/Immigration Status Employment Authorization Document Title Document Title Document Title Issuing Authority Issuing Authority Issuing Authority Document Number Document Number Document Number Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy) Document Title QR Code - Sections 2 3 Do Not Write In This Space Additional Information Issuing Authority 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..

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