19. Attachment 12 Contractor Security Screening Packet.pdf

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Jeong, Esther (CTR)

11.0.0.20130303.1.892433

DHS Form 11000-25

CONTRACTOR FITNESS / SECURITY SCREENING REQUEST FORM

Section II: Applicant Information

Please refer to the appended instructions when completing this form. Incomplete forms will be returned. This form must be submitted electronically to by the CO, COTR, or Federal POC.

Section I: Requesting Official/Organization

1.

Date of Submission

2.

DHS Organization

3.

Type of Request

4.

Exit Request Reason

5a.

CO:

Phone

DHS Email

5b. COTR/Federal POC:

Phone

DHS Email

6.

Prime Contractor

7. Prime Contract No.

8.

Task Order No.

9.

PIV Required

10.

DHS Organization Structure Code

11.

Applicant Name

12.

Position Title

13.

SSN

14.

Gender

15.

Place of Birth

16.

Date of Birth

17.

U.S. Citizen

18.

Phone

19. Email

Section III: Position Designation

20.

Position Risk Level

Section IV: Position Security Clearance Requirement

21.

Security Clearance Level

22.

DD254 on File

Privacy Act Information

Authority: 5 U.S.C. 5701-5733, Sections 5701-5733 and Executive Order 9397. Purpose: To facilitate the screening of applicants for contractor positions. Disclosure: Participation is voluntary; however, failure to provide this information may delay processing.

1 Indicates fields required for completing an Exit Request.

Last

First

Middle

City

State

Country (if not U.S.)

Name

Name

Last

First

Last

First

UNCLASSIFIED//FOR OFFICIAL USE ONLY

Complete this section for UNCLASSIFIED CONTRACTS ONLY. Note: Low Risk is used for Building Access ONLY, where the position will not require access to DHS systems or information.

Complete this section for CLASSIFIED CONTRACTS ONLY. Note: A DD254 form is required for all contractor positions requiring a security clearance, and should be on file with ISPB.

DEPARTMENT OF HOMELAND SECURITY

CONTRACTOR FITNESS/SECURITY SCREENING REQUEST FORM

DHS Form 11000-25 (7/17)

Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request

General

The DHS form 11000.25, Contractor Fitness/Security Screening Request is used by DHS federal employees to request that the Office of Security, Personnel Security Division (PSD) perform the appropriate fitness screening on contract employees based on the risk levels of their positions. The risk level is based on an overall assessment of the damage that an untrustworthy individual could cause to the efficiency or the integrity of DHS operations. When determining risk levels, program officials may compare the individual’s duties, responsibilities, and access with those of DHS federal employees in similar positions.

The position designation is critical to the contractor fitness process in that it determines the Investigative requirements associated with the position. For example, the minimum investigative standard for a Moderate Risk Public Trust position is a Tier-2 investigation conducted within the last 5 years. If, during the fitness process, it is determined that the individual has been investigated by another Federal agency, DHS will use the investigation(s) whenever practical. However, if the investigation is out of date or not at the required level for the position, DHS will need to initiate a new background investigation and incur the costs associated with the investigation. Therefore, it is extremely important that the appropriate position designation be made on the initial request to avoid the additional cost and time associated with position changes that may require higher level investigations.

On Classified Contracts, a few or all of the positions may require access to national security information (NSI). In this case, the contract employee must have an active clearance at, or higher than, the level designated by the DHS position. Please note that DHS does not grant security clearances to contract employees.

Contract Employee Clearances - DHS recognizes contract employee clearance levels based on the risk or access level designated to the DHS contract position. For example, a contract employee may be eligible through his company and the Department of Defense Consolidated Adjudications Facility (DoD CAF) for access at the Top Secret level; however, if the DHS contract position is designated at the Secret level, then the position and associated PIV card or badge is marked at the Secret level, not the Top Secret level. Using the same example, if the DHS position is designated as a Public Trust position (i.e., unclassified contracts – low through high risk), then the position and associated PIV card or badge is marked with no security clearance. In other words, the security clearance level is to be associated with the position, and not the individual.

Section I: Requesting Official/Organization

Please complete all fields in Section I.

For 3. Type of Request, select one of the following request types:

Contract Change – Select if the contract employee is changing contracts or is transferring from one Directorate to another.

w

Exit Request – Select if the contract employee has left the contract position.

Please note that only those fields marked with 1 are required to be completed for an Exit Request.

o w w w w w w w

Multiple Contracts – Select if it is known in advance that the contract employee is working on two or more contracts.

Name Change – Select if the contract employee has legally changed his/her last name.

New Request – Select if the contract employee is new to the Office or Directorate.

Position Change – Select if the duties of the contract position require a higher or lower level of access or risk (e.g., clearance upgrade/downgrade; TECS access upgrade/downgrade).

Reinvestigation – Select if one of the following conditions apply:

a.

Contract employee has an investigation that was completed after the date of submission of the last 11000.25 form.

Important: If there is an investigation that was recently updated, the submitter of the current 11000.25 form must provide proof of the completed investigation.

b.

Contract employee requires an updated investigation to be initiated by the Security Office.

Temporary Position – Select if the contract employee will be on the contract for 180 days or less.

DHS Form 11000-25 (7/17)

Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request

The following definition is provided to assist with the completion of this section:

DHS Organization Structure Code – The DHS Organization Structure Code is the 18-digit code used by DHS to identify the Division sponsoring the request. If you are not sure of the code for your organization, please contact your Human Resource Liaison.

Section II: Applicant Information

Please complete all fields in Section II.

Section III: Position Designation

Please complete this section for positions associated with UNCLASSIFIED Contracts, or Classified contracts where the position requested does not require a Clearance. Only one risk level should be selected in either the Non-IT or IT Position category.

The following field definitions are provided to assist with the completion of this section:

Non-IT versus IT Positions

Information Technology (IT) – Systems and services used in the automated acquisition, storage, manipulation, management, movement, control, display, switching, interchange, transmission, assurance, or reception of information. Information technology includes computers, network components, peripheral equipment, software, firmware, services, and related sources.

Information Technology (IT) Position – Positions that manage, supervise, lead, administer, develop, deliver, or support information technology (IT) systems and services. Positions where the paramount requirement is knowledge of IT principles, concepts, and methods; e.g., data storage, software applications, and networking. (e.g., IT Worker)

Non-Information Technology (IT) Position – Positions where the paramount requirement is the knowledge of other subject-matter principles, concepts, and methods. These positions may require the knowledge of the application of information technology to the assignment area or may require skill in use of IT software and hardware systems, but are not directly involved in development, delivering or supporting IT systems and services. (e.g., IT User)

Risk Levels

Low Risk (N) – Low Risk positions have the potential for limited impact on the integrity and efficiency of the service. These positions involve duties and responsibilities of limited relation to the agency or program mission.

o

Please note that Low Risk is used for Building Access ONLY, where the position will not require access to DHS systems or information.

Moderate Risk (5N/5C) – Moderate Risk positions have the potential for moderate to serious impact on the integrity and efficiency of the service. These positions involve duties that are of considerable importance to the agency or program mission, with significant program responsibility or delivery of service.

High Risk (6N/6C) – High Risk positions have the potential for exceptionally serious impact on the integrity and efficiency of the service. These positions involve duties that are especially critical to the agency or the program mission with a broad scope of responsibility and authority.

DHS Form 11000-25 (7/17)

Section IV: Position Security Clearance Requirement

Please complete this section for positions associated with CLASSIFIED Contracts. Please note that a DD-254 form is required for all contractor positions requiring a security clearance, and must be on file with the DHS Industrial Security Program Branch (ISPB). For positions not requiring a clearance, please indicate a Position Designation in Section III above.

Important: By selecting the DD254 on File checkbox, you are verifying that a DD-254 is on file for the contract identified above. To verify DD254 information, please contact DD254administrativesecurity@hq.dhs.gov.

Instructions - Completing DHS Form 11000.25, Contractor Fitness/Security Screening Request

Electronic Transmittal of DHS Form 11000.25

Important: DHS Personnel Security Division (PSD) will only accept DHS 11000.25 forms submitted by DHS Contracting Officer Representatives (CORs) or Federal Points of Contact (POCs). DHS 11000.25 forms submitted electronically by Contract Employees or Contractor Company representatives will not be processed.

1)

Complete the DHS Form 11000.25, Contractor Fitness/Security Screening Request;

2)

Scan the file (if applicable);

3)

Password-Protect the File;

a.

To password-protect the file, go to Tools – Protect & Standardize and click on the Protect icon.

b.

Expand the Encrypt dropdown at the top of the screen, and select the Encrypt with Password option. In the resulting pop-up window (“Are you sure you want to change the security on this document?”), select Yes.

c.

Select the checkbox next to the Require a password to open the document option towards the top of the window – enter a password in the Document Open Password text field, and click OK. In the resulting confirmation window, re-enter the password and click OK.

d.

Upon saving and closing the form, the password provided will be required to open.

4)

Save the file using the following file-naming convention: ApplicantLastNameRequestDate (MM/DD/YYYY) (e.g., Smith12042008.pdf)

5)

Email the file as an attachment to with a Subject line of "DHS Directorate – 11000.25 Request – Date” (e.g., OPO – 11000.25 Request – 11/20/2008).

6)

In a second email to the Office of Security using the same Subject line, send the password used to protect the information contained in the attachments.

Note: Please create or scan only one DHS form 11000.25 within a file attachment. If sending multiple attachments in a single email message, please use the same password for all attachments contained within the message.

DHS Form 11000-25 (7/17)

Please refer to the appended instructions when completing this form. Incomplete forms will be returned. This form must be submitted electronically to by the Contracting Officer, Contracting Officer's Technical Representative, or Federal point of contact. Select from list.: Select

Section 1. Requesting Official / Organization. 1. Date of Submission. Enter 2 digit month, 2 digit day and 4 digit year. Field required for completing an Exit Request.:

2. D H S Organization. Field required for completing an Exit Request.: Select

3. Type of Request.: Select

4. Exit Request Reason. Field required for completing an Exit Request.: None

5. A. Contract Officer. Last Name. Field required for completing an Exit Request.:

5. A. Contract Officer. First Name.:

5. A. Contract Officer. Phone Number.:

5. A. Contract Officer. D H S Email Address. Field required for completing an Exit Request. Field required for completing an Exit Request.:

5b. Contracting Officer's Technical Representative / Federal Point of Contact. Last Name. Field required for completing an Exit Request.:

5b. Contracting Officer's Technical Representative / Federal Point of Contact. First Name. Field required for completing an Exit Request.:

5b. Contracting Officer's Technical Representative / Federal Point of Contact. Phone Number.:

5b. Contracting Officer's Technical Representative / Federal Point of Contact. D H S Email. Field required for completing an Exit Request.:

6. Prime Contractor.:

7. Prime Contract Number.:

8. Task Order Number.:

9. PIV Required. Select from list.: Select

10. D H S Organization Structure Code.:

Section 2. Applicant Information. 11. Applicant Last Name. Field required for completing an Exit Request.:

11. Applicant First Name. Field required for completing an Exit Request.:

11. Applicant Middle Name. Field required for completing an Exit Request.:

12. Position Title. Field required for completing an Exit Request.:

13. Social Security Number. Field required for completing an Exit Request.:

14. Gender. Select from list.: Select

15. Place of Birth. City.:

15. Place of Birth. State. Select State from list.: Select

15. Place of Birth. Country (if not U. S.) Select from list.: Select

16. Date of Birth. Enter 2 digit month, 2 digit day and 4 digit year.:

17. U.S. Citizen.: Off

18. Phone Number.:

19. Email.:

Section 3. Position Designation. Complete this section for UNCLASSIFIED CONTRACTS ONLY. Note. Low Risk is used for Building Access ONLY, where the position will not require access to D H S systems or information. 20. Position Risk Level. Select from list.: Select

Section 4. Position Security Clearance Requirement. Complete this section for CLASSIFIED CONTRACTS ONLY. Note: A D D 2 54 form is required for all contractor positions requiring a security clearance, and should be on file with I S P B. 21. Security Clearance Level. Select from list. : Select

22. D D 2 54 on File.: Off

5. Email the file as an attachment to. Select from list.: Select viewer may not be able to display this type of document.

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Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other

DHS 11000-25 Additional Questions

To be completed by CO/COR/PM

4. Is the Applicant a Dual Citizen?

5. Does the Applicant require access to IT systems? (i.e.: FLETC E-Mail, SASS, FLETC Network etc...)

** A PIV card is no longer required for Tier 1 or Tier 2 positions that DO NOT require access to IT systems. The contractors will still receive a Tier 1 or Tier 2 background investigation, but will be issued a Proximity Card.

OSPR/PER 09/22

6. Is the Applicant working on multiple contracts or Task Orders?

** If working on multiple contracts, a complete packet is required for each contract the Applicant is working on.

Adobe Designer Template

11.0.0.20130303.1.892433.888391

Employment Application

EmployeeName:

Address:

ZipPostalCode:

CheckBox1: 0

CheckBox1: 0

CheckBox2: 0

CheckBox2: 0

CheckBox3: 0

CheckBox4: 0

Form Approved:

OMB No. 3206-0182 Declaration for Federal Employment*

(*This form may also be used to assess fitness for federal contract employment)

Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. Most applicants are asked to complete this form after a tentative offer of employment has been made; however, depending on your position, you may be asked to complete this form earlier during the hiring process. Follow instructions that the agency provides. Before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

General Information

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER 3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

YES NO (If "NO", provide country of citizenship)

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.) 6. PHONE NUMBERS (Include area codes)

Day

Night

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

Military Service

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If your only active duty was training in the Reserves or National Guard, answer "NO.”

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

YES NO

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relativeworks.

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

Continuation Space / Agency Optional Questions

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? Date:

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

YES NO DO NOT KNOW

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

BranchRow1:

From MMDDYYYYRow1:

To MMDDYYYYRow1:

BranchRow2:

From MMDDYYYYRow2:

To MMDDYYYYRow2:

BranchRow3:

From MMDDYYYYRow3:

To MMDDYYYYRow3:

Date:

Appointing Officer Enter Date of Appointment or Conversion MM DD YYYY:

Date_2:

Are you a U:

S:

Citizen?: Off

Full Name:

DATE OF BIRTH MM DD YYYY:

Social Security Number:

PLACE OF BIRTH Include city and state or country:

Country of Citizenship:

Other Names Used 1:

Other Names Used 2:

Night:

Day:

Continuation of Space or Agency Specific Questions:

Have you registered with Selective Service: Off

Have you ever served in the U:

S:

Military: Off

Type of Discharge 1:

Type of Discharge 2:

Type of Discharge 3:

Have you been convicted imprisoned probation or paroled last 7 years: Off

Have you been court martialed in the last 7 years: Off

Are you currently under charges: Off

Have you been fired or debarred or quit due to a specific problem or quit after being told you would be fired: Off

Are you delinquent on any Federal debt: Off

Do any of your relatives work for the agency or government organization for which you are submitting this form: Off

Have you applied or do you receive retirement or pension benefits from the military Federal or D:

C:

government: Off

When did you leave your last Federal job:

Did you waive Basic Life Insurance or any type of optional life insurance: Off

If yes to 18b did you later cancel the waivers: Off

Male: Off

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9

OMB No.1615-0047 Expires 07/31/2026

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

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) First Name (Given Name) Middle Initial (if any) Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number (if any) City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's Email Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1. A citizen of the United States

2. A noncitizen national of the United States (See Instructions.)

3. A lawful permanent resident (Enter USCIS or A-Number.)

4. A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:

USCIS A-Number

OR

Form I-94 Admission Number

Foreign Passport Number and Country of Issuance

Signature of Employee Today's Date (mm/dd/yyyy)

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

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 OR List B AND List C

Document Title 1

Issuing Authority

Document Number (if any)

Expiration Date (if any)

Document Title 2 (if any) Additional Information

Check here if you used an alternative procedure authorized by DHS to examine documents.

Document Title 3 (if any)

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):

Last Name, First Name and Title of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy)

Employer's Business or Organization Name Employer's Business or Organization Address, City or Town, State, ZIP Code

For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

Form I-9 Edition 08/01/23 Page 1 of 4 http://www.uscis.gov/I-9 https://www.uscis.gov/i-9 https://www.uscis.gov/i-9

LISTS OF ACCEPTABLE DOCUMENTS

All documents containing an expiration date must be unexpired.

* Documents extended by the issuing authority are considered unexpired.

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

Examples of many of these documents appear in the Handbook for Employers (M-274).

LIST A

Documents that Establish Both Identity and Employment Authorization OR

LIST B

Documents that Establish Identity

LIST C

Documents that Establish Employment

Authorization AND

1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Employment Authorization Document that contains a photograph (Form I-766) 2. Certification of report of birth issued by the

Department of State (Forms DS-1350, FS-545, FS-240)

3. School ID card with a photograph5. For an individual temporarily authorized to work for a specific employer because of his or her status or parole:

a. Foreign passport; and

b. Form I-94 or Form I-94A that has the following:

(1) The same name as the passport; and

(2) An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

4. Voter's registration card 3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

5. U.S. Military card or draft record

6. Military dependent's ID card

4. Native American tribal document

7. U.S. Coast Guard Merchant Mariner Card

5. U.S. Citizen ID Card (Form I-197)

8. Native American tribal document

6. Identification Card for Use of Resident

Citizen in the United States (Form I-179)9. Driver's license issued by a Canadian government authority

7. Employment authorization document issued by the Department of Homeland Security

For examples, see Section 7 and Section 13 of the M-274 on uscis.gov/i-9-central.

The Form I-766, Employment Authorization Document, is a List A, Item Number 4. document, not a List C document.

For persons under age 18 who are unable to present a document listed above:

10. School record or report card

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Acceptable Receipts May be presented in lieu of a document listed above for a temporary period.

For receipt validity dates, see the M-274.

● Receipt for a replacement of a lost, stolen, or damaged List A document.

● Form I-94 issued to a lawful permanent resident that contains an I-551 stamp and a photograph of the individual.

● Form I-94 with “RE” notation or refugee stamp issued to a refugee.

Receipt for a replacement of a lost, stolen, or damaged List B document.

Receipt for a replacement of a lost, stolen, or damaged List C document.

*Refer to the Employment Authorization Extensions page on I-9 Central for more information.

Form I-9 Edition 08/01/23 Page 2 of 4 https://www.uscis.gov/i-9-central/handbook-for-employers-m-274/60-evidence-of-status-for-certain-categories https://www.uscis.gov/i-9-central/form-i-9-resources/handbook-for-employers-m-274/120-acceptable-documents-for-verifying-employment-authorization-and-identity/123-list-c-documents-that-establish-employment-authorization https://www.uscis.gov/i-9-central https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents/employment-authorization-extensions

Supplement A, Preparer and/or Translator Certification for Section 1

Supplement A OMB No. 1615-0047

Last Name (Family Name) from Section 1. First Name (Given Name) from Section 1. Middle initial (if any) from Section 1.

Instructions: This supplement must be completed by any preparer and/or translator who assists an employee in completing Section 1 of Form I-9. The preparer and/or translator must enter the employee's name in the spaces provided above. Each preparer or translator must complete, sign, and date a separate certification area. Employers must retain completed supplement sheets with the employee's completed Form I-9.

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 Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name) Middle Initial (if any)

Address (Street Number and Name) City or Town State ZIP Code

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

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

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

Form I-9 Edition 08/01/23 Page 3 of 4

Supplement B, Reverification and Rehire (formerly Section 3)

Supplement B OMB No. 1615-0047

Last Name (Family Name) from Section 1. First Name (Given Name) from Section 1. Middle initial (if any) from Section 1.

Instructions: This supplement replaces Section 3 on the previous version of Form I-9. Only use this page if your employee requires reverification, is rehired within three years of the date the original Form I-9 was completed, or provides proof of a legal name change. Enter the employee's name in the fields above. Use a new section for each reverification or rehire. Review the Form I-9 instructions before completing this page. Keep this page as part of the employee's Form I-9 record. Additional guidance can be found in the Handbook for Employers: Guidance for Completing Form I-9 (M-274)

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

Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Middle Initial

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title Document Number (if any) 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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

Name of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy)

Additional Information (Initial and date each notation.) Check here if you used an alternative procedure authorized by DHS to examine documents.

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

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show

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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

Name of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy)

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

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show

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 documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

Name of Employer or Authorized Representative Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy)

Form I-9 Edition 08/01/23 Page 4 of 4 https://www.uscis.gov/i-9-central/form-i-9-resources/handbook-for-employers-m-274

3 A lawful permanent resident Enter USCIS or ANumber:

Signature of Employee:

Last Name Family Name from Section 1:

First Name Given Name from Section 1:

Middle initial if any from Section 1:

First Name Given Name:

Employee Middle Initial (if any):

Employee Other Last Names Used (if any):

Today's Date mmddyyy:

List A:

Document 2:

Expiration Date (if any):

Document Title 3:

If any:

Document 3:

Enter Issuing Authority:

Document 3 Number:

If any:

List B Document 1 Title:

Additional Information:

Middle initial if any from Section 1-2:

Sig Date mmddyyyy 1:

Sig Date mmddyyyy 0:

Sig Date mmddyyyy 2:

Sig Date mmddyyyy 3:

Signature of Preparer or Translator 0:

Signature of Preparer or Translator 1:

Signature of Preparer or Translator 2:

Signature of Preparer or Translator 3:

Preparer or Translator Last Name (Family Name) 0:

Preparer or Translator Last Name (Family Name) 2:

Preparer or Translator Last Name (Family Name) 3:

Preparer or Translator Address (Street Number and Name) 0:

Preparer or Translator Address (Street Number and Name) 1:

Preparer or Translator Address (Street Number and Name) 2:

Preparer or Translator Address (Street Number and Name) 3:

Preparer or Translator First Name (Given Name) 0:

Preparer or Translator Last Name (Family Name) 1:

Preparer or Translator First Name (Given Name) 2:

Preparer or Translator First Name (Given Name) 3:

Preparer or Translator City or Town 0:

Preparer or Translator City or Town 1:

Preparer or Translator City or Town 2:

Preparer or Translator City or Town 3:

Preparer State 0: [ ]

Preparer State 1: [ ]

Preparer State 2: [ ]

Preparer State 3: [ ]

Zip Code 0:

Zip Code 1:

Zip Code 2:

Zip Code 3:

CB_1: Off

CB_2: Off

CB_3: Off

CB_4: Off

Date of Rehire 0:

Date of Rehire 1:

Date of Rehire 2:

Todays Date 0:

Todays Date 1:

Todays Date 2:

Last Name 0:

Last Name 1:

Last Name 2:

First Name 0:

First Name 1:

First Name 2:

Middle Initial 0:

Middle Initial 1:

Middle Initial 2:

PT Middle Initial 0:

PT Middle Initial 1:

PT Middle Initial 2:

PT Middle Initial 3:

Document Title 0:

Document Title 2:

Document Number 0:

Document Number 1:

Document Number 2:

Expiration Date 0:

Expiration Date 2:

Expiration Date 1:

Name of Emp or Auth Rep 0:

Name of Emp or Auth Rep 1:

Name of Emp or Auth Rep 2:

Signature of Emp Rep 0:

Signature of Emp Rep 1:

Signature of Emp Rep 2:

CB_Alt_0: Off

CB_Alt_1: Off

CB_Alt_2: Off

Addtl Info 0:

Addtl Info 2:

Addtl Info 1:

CB_Alt: Off

Last Name Family Name from Section 1-2:

First Name Given Name from Section 1-2:

State: [ ]

ZIP Code:

Date of Birth mmddyyyy:

US Social Security Number:

Telephone Number:

Last Name (Family Name):

Address Street Number and Name:

Apt Number (if any):

City or Town:

Employees E-mail Address:

Exp Date mmddyyyy:

USCIS ANumber:

Form I94 Admission Number:

Foreign Passport Number and Country of IssuanceRow1:

Document Title 1:

Issuing Authority 1:

Document Number 0 (if any):

Document Title 2 If any:

Issuing Authority_2:

Document Number If any_2:

Document Number if any_3:

List C Expiration Date 1:

List C Document Number 1:

List C Issuing Authority 1:

List C Document Title 1:

FirstDayEmployed mmddyyyy:

S2 Todays Date mmddyyyy:

Last Name First Name and Title of Employer or Authorized Representative:

Signature of Employer or AR:

Employers Business or Org Name:

Employers Business or Org Address:

Expiration Date if any:

List B Issuing Authority 1:

List B Document Number 1:

List B Expiration Date 1:

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