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NIK
 IMPlOm
 INFORMATION
 FORM
rhia
 tofor.aUoo
 if «ll
 be
 tratt.d
 *
 cooftdential.
 It it
 r.quir.d for
 fedoril
 start
*«ForHBa*.
 PifiSf
 COMPtm
 All
 ITIKS.
 
*
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 7
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 r
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 Bac^
 (Check
 On
)
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 Aaericafl
 Indiin/AiatkiB
 Detive
 (At)
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 B)
 
Hiepaalc
 (HIS)
LJ
 Aei*n
 AnerUati/Pecific
 leleader
2,
 »«pt
FIRE:
3. Job Title
 
Sex
 (Chock
 One)
D
9.
 Date
 of
 Birth
 (Tear,
 Month,
fa.elo
 (f)
 K
Male (M)
TE:
(W)
10. Merita)
 Statue
(Check
 Oae)
 
SiofU
 0)
 f3 *.rrt«d
 (2)
(4)
 Q
S.p.r.t.d
 (S)
12.
 Cto
 you
 ap««k, r«»d,
 or writ*
 any
 laafusfe othar
 thu
 » Tl«h?
If
 ye».
 Hat
 what
 laatft>t«««
 ud
 ebtch type
 «nd
 d«|ree of
 fluency7
IS. Kdaotton
 ««rond
 Bich School
 
Attach
 «<fdition>l
 tt««t
 If
 nec«»»*rr.
 y
of
 School
 or
 C«JI»t*
 Oatea
 Attended Major
 Graduated
 Decree Credit*
m
16.
 ti«t
 any
 ep eeiel
 lic«o§*»
 or
 etrtiflcttioae required
 for
 your
 Jok
 cod
 mny
 other*
.
 4pprej»wre,
 Burxyoie,
 a)te.—fAttach-»JUitig«Hil
 aheat
 if
Type
 of
 lie
or
 C
 rt
leeuo
 Hate
ixpiretioo
 
Bo
 you
 hate
ticeneo
the
-----
 Kxpipetion
 Vet.
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 (.-•
laitlala
 of
 Peparti«at
Hepre»«nt«tiv».
MIS
 SICTXOB
 UBI8VBD
 fOfi
 PBHSOVNIt
 OlPAXTMJtlfT
 USX
 OMIY
S»pior««
 Number
 _
 Adjuatod
 Service
 Bate
 
Department
 of Homeland
Security
U S
Citizenship
 and
 Immigration Services
OMB
 No.
 1615-0047;
 Expires
 03/31/07
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. EmployersCANNOT 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:FirstMiddle
 Initial
|
Maiden
 Name
Apt.
 #Date of
 Birth
 (month/day/year)
Zip
 Code
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
 attesL
 under penalty
 of
 perjury, that
 I am
 (check
 one of the
 following):
p
A
 citizen
 or
 national
 of the
 United
 States
Q
A
 Lawful Permanent
 Resident (Alien
 #)
 A
[H
An
 alien
 authorized
 to
 work
 until
(Alien
 
or
 Admission
 #)mployee's
 Signature
and/or TranslatoYvertification.
 (To be
 completed
 and
 signed
 if
 Section
 1 is
 prepared
 by a
 person
other
 than
 Ihe
 employee.)
 I
 attest,
 under penalty
 of
 perjury,
 that
 I
 have assisted
 in the
 completion
 of
 this
 formand thai to the
 best
of
 my
 knowledge
 the
 information
 is true and
 correct.
Preparer's/Translator's
 Signature
Print
 Name
 ress
 (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
Document
 title:
OR
 List
 B
Cheer
 i
AND
List C
Issuing authority:Document #:
Expiration
 Date
 (if
 any :
Document #:Expiration Date
 (if
 any :
CERTIFICATION - (attest,
 under penalty
 of
 perjury,
 that
 I
 have
 examined the
 documents) 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)
 £
I
 ^ ^f
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.)
Section 3. Updating and
l
 signed
 by
 employer.
HARTFORD,
 CONN
 06103
 
New
 Name
 tt
 applicable)
B. Date of
 Rehire
 (month/dayfyear)
 (if applicable)
C.
 If employee's previous grant of
 work
 authorization has expired, provide the information below for the document that establishes current employmentDocument
 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
 documents),
 the documents) I
 have
 examned appear
 to be
 genuine
 and to relate to the
 Individual.
Signature of Employer or Authorized
 Representative
Date
 (month/dayfyear)
NOTE: This Is the 1991
 edition
 of the Form I-9 that has been rebranded with acurrent printing
 date
 to
 reflect
 the
 recent transition
 from the INS to DHS and its
components.
Form
 1-9
 (Rev. 05/31/05)V Page
 2
 
12.
 SPECIAL QUALIFICATIONS
 AND
 SKILLS
A.
 List
 licenses, (include
 driver's
 license
 or
 commercial
 driver's
 license A, B or C) or
certifications
 which you
 possess
 for any type of
 work.
 Also
 list
 the
 state
 or
 other licensing
authority
 which
 granted
 it and
 applicable operator
 numbers
 and
 expiration
 dates:
GPL
 CJ£I&~^
 IVTrtrr-TmKer
Pqnipfr-YTen"t
B.
 List
 any
 special
 skills,
 machines
 and equipment which you can
 operate
 (include
 typing
 speed
if
 appropriate}
 which
 may qualify you for the
 position
 for which you are
 applying:
J.
 Rm firriEtnWvt
 UjHh
Ecr^i
(ijctnla
-Sble,
C.
 Give
 any
 special
 qualificatjpris,npt
 covered
 elsewhere
 in
 this
 application, such
 as (1)
 yourpublications;
 (2)
 membership
 in
 professional organizations;
 (3)
 honors
 and
 awards received:
D.
 List
 all
 computer programs
 with
 which
 you are
 proficient;
 MS
Word,
 MS
Access,
 Excel, etc.:
E.
 Can you
 speak,
 read or write any language other than
 English?
If
 Yes, indicate language
 and
 check type
 and
 degree
 of
 fluency:
Yes
Language
Speak
Read
Write
Excellent
I
 I
 Good
 I I
 Fair
 I I
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 2 of 5

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