New Hire Packet 2024

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status. or national origin may be illegal.

Form I-9

OMB No.1615-0047

Expires 07/31/2026
Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.
Name*

First Name Given NameMiddle Initial if anyLast Names
Other Last Name Used (if any)
Address Street Number and Name*
Apt Number if any
City or Town*
State*
ZIP Code*
Date of Birth*

MonthDayYear
Date
US Social Security Number*
Employees Email Address*
example@example.com
Employees 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):*

A cititzen of the United StatesA noncitizen national of the United States (See Instructions)A lawful permanent resident (Enter USCIS or A-Number)A noncitizen (other than item Numbers 2. and 3. above) authorized to work until
USCIS ANumber (if applicable)
Form I94 Admission Number (if applicable)
Foreign Passport Number and Country of Issuance (if applicable)
Signature of Employee*

Clear
Todays Date *

MonthDayYear
Date
Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions. List C List B List A
List A Document Title 1
Document Title
Issuing Authority- Doc. 1
Document Number (if any)- 1
Expiration Date (if any)- 1

MonthDayYear
Date
List A Document Title 2 (if any)
Document Title
Issuing Authority
Document Number (if any) -2
Expiration Date (if any) - 2

MonthDayYear
Date
List A Document Title 3 (if any)
Document Title
Issuing Authority- Doc. 3
Document Number (if any) - 3
Expiration Date If any

MonthDayYear
Date
List B
Documentation 1 - List B
Issuing Authority
Document Number
Expiration Date
List C
Documentation 1- List C
Issuing Autority- List C
Document Number - List C
Expiration Date
Check here if you used an alternative procedure authorized by DHS to examine documents.

YES
Additional Information
Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the abova-named employee, (2) the above-listed documentation appears to be genuino 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.
Last Name, First Name and Title of Employer or Authorized Representative
First Day of Employment
Signature of Employer or Authorized Representative

Clear
Todays Date

MonthDayYear
Date
Employers Business or Organization Name
Employer's Business or Organization Address City or Town State ZIP Code
For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

LISTS OF ACCEPTABLE DOCUMENTS
LISTS OF ACCEPTABLE DOCUMENTS

All documents containing an expiration date must be unexpired. * Documents extended by the issuing authority are considered unexpired. Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

Examples of many of these documents appear in the Handbook for Employers (M-274).

LIST A: Documents that Establish Both Identity and Employment Authorization

1. U.S. Passport or U.S. Passport Card

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine- readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For an individual temporarily authorized to work for a specific employer because of his or her status or parole:

a. Foreign passport: and

b. Form 1-94 or Form I-94A that has the following:

(1) The same name as the passport; and

(2) An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

OR

LIST B: Documents that Establish Identity

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

3. School ID card with a photograph

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

9. Driver's license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

LIST C: Documents that Establish Employment Authorization

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

5. U.S. Citizen ID Card (Form I-197)

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

7. Employment authorization document issued by the Department of Homeland Security

For examples. see Section 7 and Section 13 of the M-274 on uscis.gov/i-9-central.

The Form I-766, Employment Authorization Document, is a List A, Item Number 4. document, not a List C document.

Acceptable Receipts: May be presented in lieu of a document listed above for a temporary period. For receipt validity dates, see the M-274.

Receipt for a replacement of a lost, stolen, or damaged List A document.

Form I-94 issued to a lawful permanent resident that contains an I-551 stamp and a photograph of the Individual.

Form I-94 with "RE" notation or refugee stamp issued to a refugee.

Receipt for a replacement of a lost stolen or damaged List B document

Receipt for a replacement of a lost stolen or damaged List C document
Would you like to upload a document from List A, or one from List B and one from list C?*

Upload One Document from List AUpload One Document from List B and One from List C
Image Upload - Passport upload only

Place document on a flat well lite service and take photo to upload here.
File Upload*

Cancelof
Image Upload - Document 1 (List B)

Place document on a flat well lite service and take photo to upload here.
File Upload*

Cancelof
Image Upload - Document 2 (List C)

Place document on a flat well lite service and take photo to upload here.
File Upload*

Cancelof
Image Upload - Voided Check or Documentation from Financial Instution providing routing and account number information.

Place document on a flat well lite service and take photo to upload here.
File Upload*

Cancelof

Racial and Ethnicity Data Collection
Location*
The federal government has developed definitions for six racial and ethnic categories. HCCSC files a report every other year with the Equal Employment Opportunity Commission reporting ethnic and racial informationabout staff. Please completeboth Part 1. If you answer No to Part 1, please answer all that apply in Part 2.
Part 1: Are you Hispanic/Latino (choose only one)*

No, not Hipanic/LatinoYes, Hispanic/Latino - A person of cuban, Meican, Puerto Rican, South or Central America, or other Spanish culture or origin, regadelss of race
Part 2: What is your race? (choose one or more)*

American Indian or Alaskan Native: A person having origins in any of the original peoples of NorthAmerican and maintaining cultural identification through tribalaffiliation or community recognitionAsian: A person having origins in any of the original peoples of the Far East,Southeast Asia, or the India subcontinent including Cambodia, China,India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,Thailand and VietnamBlack or Afiican American: A person having origins in any of the black racial groups of AfricaNative Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii,Guam, Samoa, or other Pacific IslandsWhite: A person having origins in any of the original peoples ofEurope, the Middle East or North Africa

STAFF EMERGENCY RESPONSE INFORMATION
Emergency Contact Name - 1*
Relationship - 1*
Phone - 1*
Emergency Contact Name- 2*
Relationship-2*
Phone-2*
Physician*
Physician Phone #*
Hospital Preference*
Permission to transport to hospital in an emergency?*

YesNo
Allergies-(please enter N/A if not applicable)*
Any medication we need to be aware of - (please enter N/A if not applicable)*
Should be Empty:

Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.

List A Document Title 1

List A Document Title 2 (if any)

List A Document Title 3 (if any)

List B

List C

LISTS OF ACCEPTABLE DOCUMENTS

Racial and Ethnicity Data Collection

STAFF EMERGENCY RESPONSE INFORMATION