Departmentof
HomelandSecurity
lJS.
Citizenship
and
ImmigrationServicesOMBNo.1615-0047;Expires08/31/12
Form
1-9,EmploymentEligibilityVerification
Readinstructionscarefullybeforecompleting
thisform.
The
instructionsmust
be
available
during
completion
ofthis
form.
ANTI-DISCRIMINATIONNOTICE:
is
illegalto
discriminate
against
work-authorized
individuals.Employers
CANNOT
specify
whichdocument s they
will
acceptfroman
employee.
The
refusalto
hireanindividual
because
the
documentshave
a
future
expiration
datemay
also
constitute
illegal
discrimination.
Date
of
Birth
month/day/year)
C
g-f
Apt.
ZipCode
~ f3
Iattest,
under
penally
of
perjury,thatI
1m
(checkoneof
the
following)
citizenoftheUnitedStates
D
A
noncitizennational
or
the
UnitedStates(see
in~truclions
DD
State
I L
I
am
aware
that
federallawprovidesfor
imprisonment
and/or
fines
for
false
statements
or
use
of
false
documents
in
connection
withthe
completion
0
his
f
m.
Print
NameLast
FirstMiddleInitialMaiden
Name
a~
City
Section
1.
Employee
Information
and
Verification
Tobecompleted
and
signedbyemployeeatthetimeemploymentbegins)
Preparerand/orTranslator
Certification
v
be
completedandsigned
if
SectionI
is
preparedbya lJersootherthantheemployee.)Iattest.underpenaltyo/perjury.that
huveassisted
in
thecompletion
o/thisjorm
andthat
to
thebest
a/my
knowledgetheinformation
is
true
and
correct.
Preparer s/Translator sSignaturePrint
Name
Address
StreetName
and
Number.City.State.ZipCode)
Date
month/day/year)
Section
2.
Employer
Review
and
Verification
Tobecompletedandsignedbyemployer.Examineonedocument/romListAORexamineonedocument/romList
andone/rom
List
C,
aslistedonthereverse
o/this/arm and
recordthetitle,number,andexpiration
date,
if
any,
rf
the
documentM
List
Documenttitle Issuingauthority:Document
'
ExpiratiDn
Date
ifany).
Document
:
OR
List
~
ListC
Expiration
Date
if
any):
CERTIFICATION:
I
attest,
under
penalty
of
perjury,that
I
haveexaminedthedocument s presented
by
theabove-named
employee,
that
the
above-listed
doeument s
appear
tobe
genuine
and
to
relate
to
the
employee
named,
that
the
employee
began
employment
on
month/day/year
.
t
3
and
that
to
the
best
of
my
knowledge
the
employee
is
authori:ted
to
worl.
in
the
United
States.
Stateemployment
agencies
mayomitthe
date
the
employeebegan
employment.
SignatureofEmpoyer
or
AuthorizedRepresentativePrint
Name
C
Il employee spreviousgrant
of
workauthorization
has
expired,provide
the
information
below
for
the
documentthatestablishescurrentemploymentauthorizationDocumentTitle:Document
:
Expiration
Date
ifany):
Inttest,underpenaltyofperjury,that
to
thebestof
my
knowledge,thisemployee
is
authorized
to
work
in
theUnitedStates,andiftheemployeepresenteddocument(s),thedocument(s)Ihaveexaminedappear
tobe
genuineand
to
relate
to
theindividual.SignatureofEmployer
or
ALlthorized
Representative
Date
month/day/year)
Fonn
1-9
Rev.
08107/09)
Y
Page
4
OATHOFLOYALTY
STATEOFFLORIDACOUNTYOF
Le~O~2
I
fJ1a hi.
D m?7
,
asacitizen
theState
Floridaand
theUnitedStates
America,andbeingemployedby
r
anofficer
theState
Floridaandarecipient
publicfundsassuchemployee
r
officer,doherebysolemnlyswear
r
affirmthatIwillsupporttheconstitution
theUnitedStatesand
theState
Florida.
Sworn
to
oraffirmed
and
subscribedbefore
me
this
tj+ft
day
of
t1/lJitlA
J/ j
?
by
--;. ilAf.
= :=: J <l_ =::Jj~~~____6~
name
ofpersonacknowledged
o
Personally
Knowng--pfQduced
as
Identification:
FIDV,dt1
D:l ,vev
i en/)t:.
type
ofidentification
. 4.-:; ~~
SHERESEGAINOUS
t::·iJ~.\
MY
COMMISSION
EE857258
§
EXPIRES:JanU8lY13
2017
~Rf
..
BondedThru
y
PublIc
UndeIwIItWs
Seal
THEFLORID LEGISL TURE
OFFICEOFHUM NRESOURCESEMPLOYEEH ND OOK CKNOWLEDGEMENT
Iherebyacknowledgereceipt
theLegislativeEmployeeHandbook.
o
Printedcopy or
LegislativeIntranetunderHumanResourcesIunderstandthatit
s
myresponsibilitytoreviewthisdocument
n
detailandrequestanyneededclarification.Ialsounderstandthatthissignedacknowledgementofreceiptwillbeapermanentpart
mypersonnelfile.
M~J
~lVIS ~
EmployeName pleasepri
t