I-9 Practice Form

Last Name (Family Name)

First Name (Given Name)

Address (Street Number and Name)

City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

U.S. Social Security Number

Employee's Email Address

Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1. A citizen of the United States 2. A noncitizen national of the United States (See Instructions.) 3. A lawful permanent resident (Enter USCIS or A-Number.) 4. An alien authorized to work until (exp. date, if any)

Signature of Employee Today's Date (mm/dd/yyyy)