WORKTERRA - Form I-9 Employment Eligibility Verification

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 (check one of the available options)

A citizen of the United States

A noncitizen national of the United States (See instructions)

A lawful permanent resident

An alien authorized to work

Alien Registration Number/USCIS Number:

Form I-94 Admission Number:

If you obtained your admission number from CBP in connection with your arrival in the United States, include the following:

Foreign Passport Number:

Country of Issuance:

error: Write your error message here.

Electronic signature

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 Name:

Date:

(in format, mm/dd/yyyy)

Section 2: Employer or Authorized Representative Review and Verification

Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employees first day of employment.You must physically examine one document from List A OR examine a combination of one document from List B and one document from List C as listed on the List of Acceptable Documents . For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.

MATT 9814 Norwalk Boulevard, Suite 100 Santa Fe Springs , CA 90670

List A: Documents that establish both Identity and Employment Authorization:

Document Title:

Alien Registration Number/USCIS Number:

Additional List A Document (if any):

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any):

(in format, mm/dd/yyyy)

List B: Documents Employment Authorization:

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any):

(in format, mm/dd/yyyy)

List C: Documents that establish Employment Authorization:

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any):

(in format, mm/dd/yyyy)

Certification

I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States:

Employee's First Day of Employment:

(in format, mm/dd/yyyy)

Name of Employer or Authorized Representative:

Date:

(in format, mm/dd/yyyy)

Title of Employer or Authorized Representative:

Employer's Business or Organization Name:

Address (Street Number and Name):

City or Town:

State :

Zip Code :

Notification

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Form I-9 Employment Eligibility Verification