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Employment Application

Applicant Information


Full Name:				Date:
	Last	First	M.I.
Address:
	Street Address		Apartment/Unit #

	City		State		ZIP Code

Phone: (

)

E-mail Address:

Are you over

Date Available:

the age of 18?:

Desired Salary:

Position Applied for:

YES

Are you a citizen of the United States?

If no, are you authorized to work in the U.S.?

YES NO

Were you referred by someone?

If so, who?

YES NO

Have you ever been convicted of a felony?

If yes, explain:

Education

High School:

Address:

YES NO

From:

To:

Did you graduate?

College:Address:

Degree:

YES NO

From:		To:		Did you graduate?
Other:					Address:

Degree:

YES NO

From:

To:

Did you graduate?

Degree:

	References
Please list three professional references.
Full Name:		Relationship:
Company:			Phone:	(	)
Address:
Full Name:		Relationship:
Company:			Phone:	(	)
Address:
Full Name:		Relationship:
Company:			Phone:	(	)
Address:

Form W-4 (2011)

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2011 expires February 16, 2012. See Pub. 505, Tax Withholding and Estimated Tax.

Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $950 and includes more than $300 of unearned income (for example, interest and dividends).

Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you may claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 919, How Do I Adjust My Tax Withholding, for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using

Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 919 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 919 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4 takes effect, use Pub. 919 to see how the amount you are having withheld compares to your projected total tax for 2011. See Pub. 919, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Personal Allowances Worksheet (Keep for your records.)

A	Enter “1” for yourself if no one else can claim you as a dependent		. . . . . . . . .	A
	Enter “1” if: {	• You are single and have only one job; or	} . . .
B	Enter “1” if: {	• You are married, have only one job, and your spouse does not work; or	} . . .	B

•Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

CEnter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more

	than one job. (Entering “-0-” may help you avoid having too little tax withheld.)	C
D	Enter number of dependents (other than your spouse or yourself) you will claim on your tax return	D
E	Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .	E
F	Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit . . .	F
	(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

GChild Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

•If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.

•If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible

child plus “1” additional if you have six or more eligible children . . . . . . . . . . . . . . . . . . G

HAdd lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H


For accuracy,	{	• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
complete all		and Adjustments Worksheet on page 2.
thatworksheetsapply.		• If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
		$40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

•If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Cut here and give Form W-4 to your employer. Keep the top part for your records.

Form	W-4	Employee's Withholding Allowance Certificate							OMB No. 1545-0074
Form	W-4	▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is							2011
Department of the Treasury
Department of the Treasury		subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Internal Revenue Service

1	Type or print your first name and middle initial.		Last name					2 Your social security number

	Home address (number and street or rural route)			3	Single	Married	Married, but withhold at higher Single rate.
				3	Single	Married	Married, but withhold at higher Single rate.
				Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

	City or town, state, and ZIP code			4	If your last name differs from that shown on your social security card,
				4
					check here. You must call 1-800-772-1213 for a replacement card. ▶
5	Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)								5
6	Additional amount, if any, you want withheld from each paycheck				. . . . . . . . . . . . . .				6 $

7I claim exemption from withholding for 2011, and I certify that I meet both of the following conditions for exemption.

•Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and

•This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature
(This form is not valid unless you sign it.) ▶			Date ▶

8	Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)	9 Office code (optional)	10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.		Cat. No. 10220Q	Form W-4 (2011)

Form W-4 (2011)	Page 2

Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1Enter an estimate of your 2011 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and

	miscellaneous deductions			1	$
	Enter: {	$11,600 if married filing jointly or qualifying widow(er)	}
2		$8,500 if head of household		2	$
		$5,800 if single or married filing separately
		$5,800 if single or married filing separately
3	Subtract line 2 from line 1. If zero or less, enter “-0-”			3	$
4	Enter an estimate of your 2011 adjustments to income and any additional standard deduction (see Pub. 919)			4	$

5Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

	Withholding Allowances for 2011 Form W-4 Worksheet in Pub. 919.)	5	$
6	Enter an estimate of your 2011 nonwage income (such as dividends or interest)	6	$
7	Subtract line 6 from line 5. If zero or less, enter “-0-”	7	$
8	Divide the amount on line 7 by $3,700 and enter the result here. Drop any fraction	8
9	Enter the number from the Personal Allowances Worksheet, line H, page 1	9

10Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,

also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)

Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
1	Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)	1

2Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more

than “3”

3If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter

“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional

	withholding amount necessary to avoid a year-end tax bill.
4	Enter the number from line 2 of this worksheet	4
5	Enter the number from line 1 of this worksheet	5
6	Subtract line 5 from line 4		6
7	Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .		7	$
8	Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .		8	$

9Divide line 8 by the number of pay periods remaining in 2011. For example, divide by 26 if you are paid

every two weeks and you complete this form in December 2010. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck	9	$

				Table 1									Table 2
Married Filing Jointly							All Others			Married Filing Jointly						All Others
If wages from LOWEST				Enter on	If wages from LOWEST				Enter on	If wages from HIGHEST			Enter on	If wages from HIGHEST			Enter on
paying job are—				line 2 above	paying job are—				line 2 above	paying job are—			line 7 above	paying job are—			line 7 above

$0	- $5,000 -			0	$0 - $8,000 -				0	$0 - $65,000			$560	$0 - $35,000			$560
5,001	-	12,000	-	1	8,001	-	15,000	-	1	65,001	-	125,000	930	35,001	-	90,000	930
12,001	-	22,000	-	2	15,001	-	25,000	-	2	125,001	-	185,000	1,040	90,001	-	165,000	1,040
22,001	-	25,000	-	3	25,001	-	30,000	-	3	185,001	-	335,000	1,220	165,001	-	370,000	1,220
25,001	- 30,000 -			4	30,001	- 40,000 -			4	335,001 and over			1,300	370,001 and over			1,300
30,001	-	40,000	-	5	40,001	-	50,000	-	5
40,001	-	48,000	-	6	50,001	-	65,000	-	6
48,001	-	55,000	-	7	65,001	-	80,000	-	7
55,001	-	65,000	-	8	80,001	-	95,000	-	8
65,001	-	72,000	-	9	95,001	-120,000		-	9
72,001	- 85,000 -			10	120,001 and over				10
85,001	-	97,000	-	11
97,001	-110,000		-	12
110,001	-120,000 -			13
120,001	-135,000 -			14
135,001 and over				15
Privacy Act and Paperwork				Reduction Act Notice. We ask for the information on this form to						You are not required to provide the information requested on a form that is
Privacy Act and Paperwork
carry out the Internal Revenue laws of the United States. Internal Revenue Code sections										subject to the Paperwork Reduction Act unless the form displays a valid OMB
3402(f)(2) and 6109 and their regulations require you to provide this information; your employer										control number. Books or records relating to a form or its instructions must be
uses it to determine your federal income tax withholding. Failure to provide a properly										retained as long as their contents may become material in the administration of
completed form will result in your being treated as a single person who claims no withholding										any Internal Revenue law. Generally, tax returns and return information are
allowances; providing fraudulent information may subject you to penalties. Routine uses of this										confidential, as required by Code section 6103.
information include giving it to the Department of Justice for civil and criminal litigation, to										The average time and expenses required to complete and file this form will vary

	cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in	depending on individual circumstances. For estimated averages, see the
	administering their tax laws; and to the Department of Health and Human Services for use in
		instructions for your income tax return.
	the National Directory of New Hires. We may also disclose this information to other countries
		If you have suggestions for making this form simpler, we would be happy to hear
	under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to
		from you. See the instructions for your income tax return.
	federal law enforcement and intelligence agencies to combat terrorism.

		OMB No. 16150047; Expires 08/31/12
	Department of Homeland Security	Form I9, Employment
	Department of Homeland Security	Eligibility Verification
	U.S. Citizenship and Immigration Services	Eligibility Verification

Instructions

Read all instructions carefully before completing this form.

AntiDiscrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the United States) 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 workauthorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents presented have a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 18002558155.

What Is the Purpose of This Form?

The purpose of this form is to document that each new employee (both citizen and noncitizen) hired after November 6, 1986, is authorized to work in the United States.

When Should Form I9 Be Used?

All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form I9.

Filling Out Form I9

Section 1, Employee

This part of the form must be completed no later than the time of hire, which is the actual beginning of employment. Providing the Social Security Number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E Verify). The employer is responsible for ensuring that Section 1 is timely and properly completed.

Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

Employers should note the work authorization expiration date (if any) shown in Section 1. For employees who indicate an employment authorization expiration date in Section 1, employers are required to reverify employment authorization for employment on or before the date shown. Note that some employees may leave the expiration date blank if they are aliens whose work authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia or the Republic of the Marshall Islands). For such employees, reverification does not apply unless they choose to present

in Section 2 evidence of employment authorization that contains an expiration date (e.g., Employment Authorization Document (Form I766)).

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 or her own. However, the employee must still sign Section 1 personally.

Section 2, Employer

For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Employers must complete Section 2 by examining evidence of identity and employment authorization within three business days of the date employment begins. However, if an employer hires an individual for less than three business days, Section 2 must be completed at the time employment begins. Employers cannot specify which document(s) listed on the last page of Form I9 employees present to establish identity and employment authorization. Employees may present any List A document OR a combination of a List B and a List C document.

If an employee is unable to present a required document (or documents), the employee must present an acceptable receipt in lieu of a document listed on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employees must present receipts within three business days of the date employment begins and must present valid replacement documents within 90 days or other specified time.

Employers must record in Section 2:

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 in Section 2. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I9. Employers are still responsible for completing and retaining Form I9.

Form I9 (Rev. 08/07/09) Y

For more detailed information, you may refer to the		Information about EVerify, a free and voluntary program that
USCIS Handbook for Employers (Form M274). You may		allows participating employers to electronically verify the
obtain the handbook using the contact information found		employment eligibility of their newly hired employees, can be
under the header "USCIS Forms and Information."		obtained from our website at www.uscis.gov/everify or by
Section 3, Updating and Reverification		calling 18884644218.
Section 3, Updating and Reverification	General information on immigration laws, regulations, and
Employers must complete Section 3 when updating and/or	General information on immigration laws, regulations, and
Employers must complete Section 3 when updating and/or	procedures can be obtained by telephoning our National
reverifying Form I9. Employers must reverify employment	procedures can be obtained by telephoning our National
reverifying Form I9. Employers must reverify employment	Customer Service Center at 18003755283 or visiting our
authorization of their employees on or before the work	Customer Service Center at 18003755283 or visiting our
authorization of their employees on or before the work	Internet website at www.uscis.gov.
authorization expiration date recorded in Section 1 (if any).	Internet website at www.uscis.gov.

Employers CANNOT specify which document(s) they will
Employers CANNOT specify which document(s) they will		Photocopying and Retaining Form I9
accept from an employee.		Photocopying and Retaining Form I9
A. If an employee's name has changed at the time this form
A. If an employee's name has changed at the time this form	A blank Form I9 may be reproduced, provided both sides are
is being updated/reverified, complete Block A.	A blank Form I9 may be reproduced, provided both sides are
is being updated/reverified, complete Block A.	copied. The Instructions must be available to all employees
B. If an employee is rehired within three years of the date	copied. The Instructions must be available to all employees
B. If an employee is rehired within three years of the date	completing this form. Employers must retain completed Form
this form was originally completed and the employee is	I9s for three years after the date of hire or one year after the
still authorized to be employed on the same basis as	date employment ends, whichever is later.
previously indicated on this form (updating), complete		Form I9 may be signed and retained electronically, as
Block B and the signature block.		Form I9 may be signed and retained electronically, as
Block B and the signature block.		authorized in Department of Homeland Security regulations
C. If an employee is rehired within three years of the date		authorized in Department of Homeland Security regulations
C. If an employee is rehired within three years of the date		at 8 CFR 274a.2.
this form was originally completed and the employee's
work authorization has expired or if a current
work authorization has expired or if a current		Privacy Act Notice
employee's work authorization is about to expire		Privacy Act Notice
(reverification), complete Block B; and:
(reverification), complete Block B; and:	The authority for collecting this information is the
1. Examine any document that reflects the employee	The authority for collecting this information is the
1. Examine any document that reflects the employee	Immigration Reform and Control Act of 1986, Pub. L. 99603
is authorized to work in the United States (see List	(8 USC 1324a).
A or C);		This information is for employers to verify the eligibility of
2. Record the document title, document number, and
2. Record the document title, document number, and		individuals for employment to preclude the unlawful hiring, or
expiration date (if any) in Block C; and
expiration date (if any) in Block C; and		recruiting or referring for a fee, of aliens who are not
3. Complete the signature block.		recruiting or referring for a fee, of aliens who are not
3. Complete the signature block.		authorized to work in the United States.
Note that for reverification purposes, employers have the		This information will be used by employers as a record of
option of completing a new Form I9 instead of completing		This information will be used by employers as a record of
Section 3.		their basis for determining eligibility of an employee to work
		in the United States. The form will be kept by the employer
What Is the Filing Fee?		and made available for inspection by authorized officials of
		the Department of Homeland Security, Department of Labor,
There is no associated filing fee for completing Form I9. This		and Office of Special Counsel for ImmigrationRelated Unfair
		Employment Practices.
form is not filed with USCIS or any government agency. Form		Employment Practices.
form is not filed with USCIS or any government agency. Form
I9 must be retained by the employer and made available for	Submission of the information required in this form is
inspection by U.S. Government officials as specified in the	Submission of the information required in this form is
inspection by U.S. Government officials as specified in the	voluntary. However, an individual may not begin employment
Privacy Act Notice below.	voluntary. However, an individual may not begin employment
Privacy Act Notice below.	unless this form is completed, since employers are subject to

	civil or criminal penalties if they do not comply with the
USCIS Forms and Information	civil or criminal penalties if they do not comply with the
USCIS Forms and Information	Immigration Reform and Control Act of 1986.

To order USCIS forms, you can download them from our
website at www.uscis.gov/forms or call our tollfree number at
18008703676. You can obtain information about Form I9
from our website at www.uscis.gov or by calling
18884644218.

EMPLOYERS MUST RETAIN COMPLETED FORM I9			Form I9 (Rev. 08/07/09) Y Page 2
DO NOT MAIL COMPLETED FORM I9 TO ICE OR USCIS

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 12 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 205292210. OMB No. 16150047. Do not mail your completed Form I9 to this address.

Form I9 (Rev. 08/07/09) Y Page 3

	OMB No. 16150047; Expires 08/31/12
Department of Homeland Security	Form I9, Employment
U.S. Citizenship and Immigration Services	Eligibility Verification

Read instructions carefully before completing this form. The instructions must be available during completion of this form.

ANTIDISCRIMINATION NOTICE: It is illegal to discriminate against workauthorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have 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. #

Date of Birth (month/day/year)

City

State

Zip Code

Social Security #


	I am aware that federal law provides for	I attest, under penalty of perjury, that I am (check one of the following):
	I am aware that federal law provides for	A citizen of the United States
	imprisonment and/or fines for false statements or	A citizen of the United States
	use of false documents in connection with the	A noncitizen national of the United States (see instructions)
	completion of this form.	A lawful permanent resident (Alien #)
		An alien authorized to work (Alien # or Admission #)
		until (expiration date, if applicable month/day/year)
	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.

Preparer's/Translator's Signature

Print Name

Address (Street Name and Number, City, State, Zip Code)

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).)
List A	OR	List B	AND	List C

Document title:

Issuing authority:

Document #:

Expiration Date (if any):

Document #:

Expiration Date (if any):

CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the abovenamed employee, that the abovelisted 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 authorized 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 and Address (Street Name and Number, City, State, Zip Code)		Date (month/day/year)

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 authorization.

Document Title:

Document #:

Expiration Date (if any):

l 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 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)

Form I9 (Rev. 08/07/09) Y Page 4

LISTS OF ACCEPTABLE DOCUMENTS

			All documents must be unexpired
	LIST A			LIST B				LIST C
	Documents that Establish Both			Documents that Establish				Documents that Establish
	Identity and Employment			Identity				Employment Authorization
	Authorization	OR			AND
1.	U.S. Passport or U.S. Passport Card		1.	Driver's license or ID card issued by			1. Social Security Account Number
				a State or outlying possession of the				card other than one that specifies
				United States provided it contains a				on the face that the issuance of the
				photograph or information such as				card does not authorize
2.	Permanent Resident Card or Alien			name, date of birth, gender, height,				employment in the United States
	Registration Receipt Card (Form			eye color, and address
	Registration Receipt Card (Form
	I551)						2. Certification of Birth Abroad


3. Foreign passport that contains a			2. ID card issued by federal, state or					issued by the Department of State
3. Foreign passport that contains a				local government agencies or				(Form FS545)
	temporary I551 stamp or temporary			entities, provided it contains a
	I551 printed notation on a machine			photograph or information such as
	I551 printed notation on a machine			photograph or information such as
	readable immigrant visa			name, date of birth, gender, height,			3. Certification of Report of Birth
				eye color, and address			3. Certification of Report of Birth
				eye color, and address				issued by the Department of State
								issued by the Department of State
								(Form DS1350)
4.	Employment Authorization Document		3.	School ID card with a photograph				(Form DS1350)
4.	Employment Authorization Document		3.	School ID card with a photograph
	that contains a photograph (Form
	I766)		4.	Voter's registration card			4. Original or certified copy of birth
			4.	Voter's registration card

								certificate issued by a State,
5. In the case of a nonimmigrant alien			5.	U.S. Military card or draft record				county, municipal authority, or
	authorized to work for a specific							territory of the United States
	employer incident to status, a foreign		6.	Military dependent's ID card				bearing an official seal
	passport with Form I94 or Form
	I94A bearing the same name as the
	I94A bearing the same name as the		7. U.S. Coast Guard Merchant Mariner			5.		Native American tribal document
	passport and containing an		7. U.S. Coast Guard Merchant Mariner
	passport and containing an			Card
	endorsement of the alien's			Card
	endorsement of the alien's
	nonimmigrant status, as long as the
	nonimmigrant status, as long as the		8. Native American tribal document
	period of endorsement has not yet		8. Native American tribal document
	period of endorsement has not yet
	expired and the proposed					6.		U.S. Citizen ID Card (Form I197)
	expired and the proposed		9. Driver's license issued by a Canadian			6.		U.S. Citizen ID Card (Form I197)
	employment is not in conflict with		9. Driver's license issued by a Canadian
	employment is not in conflict with			government authority
	any restrictions or limitations			government authority
	any restrictions or limitations
	identified on the form
	identified on the form			For persons under age 18 who			7. Identification Card for Use of
				For persons under age 18 who			7. Identification Card for Use of
				are unable to present a				Resident Citizen in the United
6. Passport from the Federated States of				document listed above:				States (Form I179)
6. Passport from the Federated States of
	Micronesia (FSM) or the Republic of
	Micronesia (FSM) or the Republic of		10.	School record or report card		8.		Employment authorization
	the Marshall Islands (RMI) with		10.	School record or report card		8.		Employment authorization
	Form I94 or Form I94A indicating							document issued by the
	nonimmigrant admission under the		11.	Clinic, doctor, or hospital record				Department of Homeland Security
	Compact of Free Association
	Between the United States and the
	Between the United States and the		12. Daycare or nursery school record
	FSM or RMI		12. Daycare or nursery school record
	FSM or RMI

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M274)

Form I9 (Rev. 08/07/09) Y Page 5

Question	Answer
Form Name	Spicy Crab Employment Application Form
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	Nonwage, I-9, noncitizen, Preparer

Spicy Crab Employment Application Form – Fill Out and Use This PDF

Spicy Crab Employment Application Form PDF Details

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Spicy Crab Employment Application Form – Fill Out and Use This PDF

Spicy Crab Employment Application Form PDF Details

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