ATTACHMENT6APPLICATIONTODODCOMMONACCESSCARDI9Form.pdf

INSTRUCTIONS

Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the U.S.) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work eligible individuals. Employers CANNOT 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. All employees, citizens and noncitizens, hired after November 6, 1986, must complete Section 1 of this form at the time of hire, which is the actual beginning of employment. The employer is responsible for ensuring that Section 1 is timely and properly completed.

examine any document that reflects that the employee is authorized to work in the U.S. (see List A or C), Preparer/Translator Certification. The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his/her own.

However, the employee must still sign Section 1 personally.

record the document title, document number and expiration date (if any) in Block C, and

Photocopying and Retaining Form I-9. A blank I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed I-9s for three (3) years after the date of hire or one

(1) year after the date employment ends, whichever is later.

Section 2 - Employer. For the purpose of completing this For more detailed information, you may refer to the Department of Homeland Security (DHS) Handbook for Employers, (Form M-274). You may obtain the handbook at your local U.S.

Citizenship and Immigration Services (USCIS) office.

Employers must complete Section 2 by examining evidence of identity and employment eligibility within three (3) business days of the date employment begins. If employees are authorized to work, but are unable to present the required document(s) within three business days, they must present a receipt for the application of the document(s) within three business days and the actual document(s) within ninety (90) days. However, if employers hire individuals for a duration of less than three business days, Section 2 must be completed at the time employment begins. Employers must record:

1) document title; 2) issuing authority; 3) document number, 4) expiration date, if any; and 5) the date employment begins.

Employers must sign and date the certification. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. These photocopies may only be used for the verification process and must be retained with the I-9.

However, employers are still responsible for completing the I-9.

Privacy Act Notice. The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).

This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States.

The form will be kept by the employer and made available for inspection by officials of the U.S. Immigration and Customs Enforcement, Department of Labor and Office of Special Counsel for Immigration Related Unfair Employment Practices.

Submission of the information required in this form is voluntary.

However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.

Section 3 - Updating and Reverification. Employers must complete Section 3 when updating and/or reverifying the I-9.

Employers must reverify employment eligibility of their employees on or before the expiration date recorded in Section 1. Employers CANNOT specify which document(s) they will accept from an employee.

Reporting Burden. We try to create forms and instructions that are accurate, can be easily understood and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex.

Accordingly, the reporting burden for this collection of information is computed as follows: 1) learning about this form, 5 minutes; 2) completing the form, 5 minutes; and 3) assembling and filing (recordkeeping) the form, 5 minutes, for an average of 15 minutes per response. If you have comments regarding the accuracy of this burden estimate, or suggestions for making this form simpler, you can write to U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachuetts Avenue, N.W., Washington, DC 20529. OMB No. 1615-0047.

If an employee's name has changed at the time this form is being updated/reverified, complete Block A.

If an employee is rehired within three (3) years of the date this form was originally completed and the employee is still eligible to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM.

form, the term "employer" includes those recruiters and referrers for a fee who are agricultural associations, agricultural employers or farm labor contractors.

Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9 (Rev. 05/31/05)YEMPLOYERS MUST RETAIN COMPLETED FORM I-9

PLEASE DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

OMB No. 1615-0047; Expires 03/31/07

Employment Eligibility Verification

If an employee is rehired within three (3) years of the date this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B and:

complete the signature block.

NOTE: This is the 1991 edition of the Form I-9 that has been rebranded with a current printing date to reflect the recent transition from the INS to DHS and its components.

A citizen or national of the United States

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 CANNOT 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.

Print Name: Last First Middle Initial Maiden Name

Address (Street Name and Number) Apt. #

(month/day/year)

Date of Birth (month/day/year)

StateCity Zip Code Social Security #

CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named

Address (Street Name and Number, City, State, Zip Code) and that to the best of my knowledge the employee

I attest, under penalty of perjury, that I am (check one of the following):

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.

A Lawful Permanent Resident (Alien #) A An alien authorized to work until

(Alien # or Admission #) is eligible to work in the United States. (State employment agencies may omit the date the employee began

Employee's Signature Date (month/day/year)

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 I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

Print NamePreparer's/Translator's Signature

Date (month/day/year)

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).

ANDList B List CORList A Document title:

Issuing authority:

Document #:

Expiration Date (if any):

Document #:

Print Name TitleSignature of Employer or Authorized Representative

Address (Street Name and Number, City, State, Zip Code) Date (month/day/year)Business or Organization Name

Section 3. Updating and Reverification. To be completed and signed by employer.

B. Date of rehire (month/day/year) (if applicable)A. New Name (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility.

Document #: Expiration Date (if any):Document Title:

l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual.

Date (month/day/year)Signature of Employer or Authorized Representative employee began employment on employment.)

Expiration Date (if any):

employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the

Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9 (Rev. 05/31/05)Y Page 2

Employment Eligibility Verification OMB No. 1615-0047; Expires 03/31/07

NOTE: This is the 1991 edition of the Form I-9 that has been rebranded with a current printing date to reflect the recent transition from the INS to DHS and its components.

LISTS OF ACCEPTABLE DOCUMENTS

LIST A LIST B LIST C

Documents that Establish Documents that Establish

OR Identity AND

(Form N-560 or N-561)

2. Certificate of U.S. Citizenship

Identity and Employment Eligibility

7. Unexpired employment

1. Driver's license or ID card 1. U.S. social security card issued

9. Driver's license issued by a Canadian government authority

1. U.S. Passport (unexpired or

I-688A) 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 by the Social Security Administration (other than a card stating it is not valid for employment)

Card (Form I-688) expired) photograph

Document (Form I-571)

Employment Eligibility

(Form N-550 or N-570)

2. Certification of Birth Abroad3. Certificate of Naturalization 2. ID card issued by federal, state issued by the Department of State (Form FS-545 or Form DS-1350)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. Unexpired foreign passport, with I-551 stamp or attached Form I-94 indicating unexpired employment authorization

3. Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal

3. School ID card with a

5. Permanent Resident Card or Alien Registration Receipt Card with photograph (Form I-151 or I-551)

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card 4. Native American tribal document

6. Unexpired Temporary Resident

7. U.S. Coast Guard Merchant Mariner Card

5. U.S. Citizen ID Card (Form7. Unexpired Employment I-197)8. Native American tribal documentAuthorization Card (Form

6. ID Card for use of Resident

8. Unexpired Reentry Permit Citizen in the United States

(Form I-179) are unable to present a document listed above:

For persons under age 18 who

9. Unexpired Refugee Travel authorization document issued by DHS (other than those listed under List A)

10. School record or report card10. Unexpired Employment Authorization Document issued by DHS that contains a photograph (Form I-688B)

11. Clinic, doctor or hospital record

12. Day-care or nursery school record

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)

Documents that Establish Both

Form I-9 (Rev. 05/31/05)Y Page 3

(Form I-327)

INSTRUCTIONS

Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the U.S.) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work eligible individuals. Employers CANNOT 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.

All employees, citizens and noncitizens, hired after November 6, 1986, must complete Section 1 of this form at the time of hire, which is the actual beginning of employment. The employer is responsible for ensuring that Section 1 is timely and properly completed.

examine any document that reflects that the employee is authorized to work in the U.S. (see List A or C), Preparer/Translator Certification. The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his/her own. However, the employee must still sign Section 1 personally.

record the document title, document number and expiration date (if any) in Block C, and

Photocopying and Retaining Form I-9. A blank I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed I-9s for three (3) years after the date of hire or one (1) year after the date employment ends, whichever is later.

Section 2 - Employer. For the purpose of completing this For more detailed information, you may refer to the Department of Homeland Security (DHS) Handbook for Employers, (Form M-274). You may obtain the handbook at your local U.S. Citizenship and Immigration Services (USCIS) office.

Employers must complete Section 2 by examining evidence of identity and employment eligibility within three (3) business days of the date employment begins. If employees are authorized to work, but are unable to present the required document(s) within three business days, they must present a receipt for the application of the document(s) within three business days and the actual document(s) within ninety (90) days. However, if employers hire individuals for a duration of less than three business days, Section 2 must be completed at the time employment begins. Employers must record: 1) document title; 2) issuing authority; 3) document number, 4) expiration date, if any; and 5) the date employment begins. Employers must sign and date the certification. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. These photocopies may only be used for the verification process and must be retained with the I-9. However, employers are still responsible for completing the I-9.

Privacy Act Notice.

The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).

This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by officials of the U.S. Immigration and Customs Enforcement, Department of Labor and Office of Special Counsel for Immigration Related Unfair Employment Practices.

Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.

Section 3 - Updating and Reverification. Employers must complete Section 3 when updating and/or reverifying the I-9. Employers must reverify employment eligibility of their employees on or before the expiration date recorded in Section 1. Employers CANNOT specify which document(s) they will accept from an employee.

Reporting Burden. We try to create forms and instructions that are accurate, can be easily understood and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. Accordingly, the reporting burden for this collection of information is computed as follows: 1) learning about this form, 5 minutes; 2) completing the form, 5 minutes; and 3) assembling and filing (recordkeeping) the form, 5 minutes, for an average of 15 minutes per response. If you have comments regarding the accuracy of this burden estimate, or suggestions for making this form simpler, you can write to U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachuetts Avenue, N.W., Washington, DC 20529. OMB No. 1615-0047.

If an employee's name has changed at the time this form is being updated/reverified, complete Block A.

If an employee is rehired within three (3) years of the date this form was originally completed and the employee is still eligible to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM.

form, the term "employer" includes those recruiters and referrers for a fee who are agricultural associations, agricultural employers or farm labor contractors.

Department of Homeland Security U.S. Citizenship and Immigration Services Form I-9 (Rev. 05/31/05)Y

EMPLOYERS MUST RETAIN COMPLETED FORM I-9

PLEASE DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

OMB No. 1615-0047; Expires 03/31/07

Employment Eligibility Verification If an employee is rehired within three (3) years of the date this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B and:

complete the signature block.

NOTE: This is the 1991 edition of the Form I-9 that has been rebranded with a current printing date to reflect the recent transition from the INS to DHS and its components.

A citizen or national of the United States 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 CANNOT 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.

Print Name: Last First Middle Initial Maiden Name Address (Street Name and Number) Apt. # (month/day/year) Date of Birth (month/day/year) State City Zip Code Social Security # CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named Address (Street Name and Number, City, State, Zip Code) and that to the best of my knowledge the employee I attest, under penalty of perjury, that I am (check one of the following):

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.

A Lawful Permanent Resident (Alien #) A An alien authorized to work until (Alien # or Admission #) is eligible to work in the United States. (State employment agencies may omit the date the employee began Employee's Signature Date (month/day/year) 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 I 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 Date (month/day/year) 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).

AND

List B List C

OR

List A Document title:

Issuing authority:

Document #:

Expiration Date (if any):

Document #:

Print Name

Title

Signature of Employer or Authorized Representative

Address (Street Name and Number, City, State, Zip Code) Date (month/day/year)

Business or Organization Name Section 3. Updating and Reverification. To be completed and signed by employer.

B. Date of rehire (month/day/year) (if applicable) A. New Name (if applicable) C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility.

Document #:

Expiration Date (if any):

Document Title:

l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual.

Date (month/day/year) Signature of Employer or Authorized Representative employee began employment on employment.)

Expiration Date (if any):

employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the

Department of Homeland Security U.S. Citizenship and Immigration Services Form I-9 (Rev. 05/31/05)Y Page 2 Employment Eligibility Verification OMB No. 1615-0047; Expires 03/31/07

NOTE: This is the 1991 edition of the Form I-9 that has been rebranded with a current printing date to reflect the recent transition from the INS to DHS and its components.

LISTS OF ACCEPTABLE DOCUMENTS

LIST A

LIST B

LIST C

Documents that Establish Documents that Establish

OR

Identity

AND

(Form N-560 or N-561)

2. Certificate of U.S. Citizenship Identity and Employment Eligibility

7. Unexpired employment

1. Driver's license or ID card

1. U.S. social security card issued

9. Driver's license issued by a Canadian government authority

1. U.S. Passport (unexpired or I-688A) 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 by the Social Security Administration (other than a card stating it is not valid for employment) Card (Form I-688) expired) photograph Document (Form I-571) Employment Eligibility (Form N-550 or N-570)

2. Certification of Birth Abroad

3. Certificate of Naturalization

2. ID card issued by federal, state issued by the Department of State (Form FS-545 or Form DS-1350) 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. Unexpired foreign passport, with I-551 stamp or attached Form I-94 indicating unexpired employment authorization

3. Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal

3. School ID card with a

5. Permanent Resident Card or Alien Registration Receipt Card with photograph (Form I-151 or I-551)

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card

4. Native American tribal document

6. Unexpired Temporary Resident

7. U.S. Coast Guard Merchant Mariner Card

5. U.S. Citizen ID Card (Form

7. Unexpired Employment I-197)

8. Native American tribal document Authorization Card (Form

6. ID Card for use of Resident

8. Unexpired Reentry Permit Citizen in the United States (Form I-179) are unable to present a document listed above:

For persons under age 18 who

9. Unexpired Refugee Travel authorization document issued by DHS (other than those listed under List A)

10. School record or report card

10. Unexpired Employment Authorization Document issued by DHS that contains a photograph (Form I-688B)

11. Clinic, doctor or hospital record

12. Day-care or nursery school record Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274) Documents that Establish Both Form I-9 (Rev. 05/31/05)Y Page 3 (Form I-327) C:\Documents and Settings\barobbs.IRMNET\Desktop\FFlow documents\I-9. 05-31-05 Final.xft 1.0 I-9. 05-31-05 Final

{CF3222A7-20FA-11D4-ABC1-00D0B71D6ABB}

i-9