U.S. Department of Justice
OMB No. 1115-0136
Immigration and Naturalization Service
Employment Eligibility Verification
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. * MANDATORY
Section 1. Employment Eligibility Verification. To be completed and signed by employee at the time employment begins.
   Last Name: *                                                      First Name: *                              Middle Initial:
        		   Maiden Name:
  
   Address (Street Name and Number): *                                                            Apt#:
   		                    Date Of Birth: *
City: * State: * Zip Code: * Social Security: # *
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 one of the following:

A Lawful Permanent Resident, enter Alien # A:     If you are an alien authorized to work, enter date until:    and your Alien# or Admission #: 
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 the 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.
   Preparer's Translator Signature.
   		    Name
  
    Address (Street Name and Number, City State, Zip Code)
   		  Date (mm/day/yr)
  _____/____/_______
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.
List A
Document Title:  
Issuing authority: 
Document #:       
Expiration Date (if any):  Document #:      
Expiration Date (if any): 
             List B




 		             List C
CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) _____/____/_____ and that to the best of my knowledge the employee is eligible to work in the United States. (State employment agencies may omit the date the employee began employment.)
  Signature of Employer or Authorized Representative
  		   Print Name
  		   Title
  
Business or Organization Name
  		Address (Street Name and Number, City, State,Zip Code)
 		 Date (mth/day/yr)
_____/___/______
Section 3. Updating and Reverification. To be completed and signed by employer.
A. New Name (if applicable)
  		 B. Date of rehire (month/day/year) (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 Title: ____________________  Document#: ______________________  Expiration Date (if any): ____/____/_______
I 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.
   Signature of Employer or Authorized Representative
     		   Date (month/day/year
    _______/________/________
                                                                                                       M-311chg: Rev 7/22/97