NIK
IMPlOm
INFORMATION
FORM
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3. Job Title
Sex
(Chock
One)
D
9.
Date
of
Birth
(Tear,
Month,
fa.elo
(f)
K
Male (M)
TE:
(W)
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(Check
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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
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Bich School
Attach
«<fdition>l
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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*
.
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Burxyoie,
a)te.—fAttach-»JUitig«Hil
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MIS
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UBI8VBD
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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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