Additional Information Initial and date each notation
/
Month
/
Day
Year
Date
Today's Date (mm/dd/yyyy)
Check here if you used an alternative procedure authorized by DHS to examine documents.
First Name and Middle Initial
*
Last Name
*
SSN
*
Single Choice
*
Option 1
Option 2
Option 3
Single Choice
Option 1
"0" if NA
*
"0" if NA
*
"0" if NA
*
"0" if NA
*
"0" if NA
*
"0" if NA
*
Signature
*
Date
*
/
Month
/
Day
Year
Date
Date of Employment
*
/
Month
/
Day
Year
Date
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Number
Phone Number
*
List A
List A
List A
List A
List A
List A
List A
List A
List A
List A
List A
List B
List C
List B
List C
List B
List C
Multiple Choice
Option 1
Name
*
First Name
Last Name
Middle Name
Short Text
Date
*
/
Month
/
Day
Year
Date
Number
*
Short Text
Short Text
Short Text
Short Text
*
Short Text
Phone Number
*
Phone Number
Phone Number
Phone Number
Date
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Date
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Date
*
/
Month
/
Day
Year
Date
Date
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Date
/
Month
/
Day
Year
Date
Date
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Date
/
Month
/
Day
Year
Date
Date
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Date
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Signature
*
Date
*
/
Month
/
Day
Year
Date
Today's Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Signature of Employer or Authorized Representative
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Name of Employer or Authorized Representative
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Document Number (if any)
Document Title
Name
First Name
Last Name
Date of Rehire (if applicable) New Name (if applicable) Date (mm/dd/yyyy) Last Name (Family Name)
/
Month
/
Day
Year
Date
Additional Information Initial and date each notation
/
Month
/
Day
Year
Date
Today's Date (mm/dd/yyyy)
Check here if you used an alternative procedure authorized by DHS to examine documents.
Today's Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Signature of Employer or Authorized Representative
Name of Employer or Authorized Representative
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Document Number (if any)
Document Title
Name
First Name
Last Name
Date of Rehire (if applicable) New Name (if applicable) Date (mm/dd/yyyy) Last Name (Family Name)
/
Month
/
Day
Year
Date
Additional Information Initial and date each notation
/
Month
/
Day
Year
Date
Today's Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Today's Date (mm/dd/yyyy)
Check here if you used an alternative procedure authorized by DHS to examine documents.
Signature of Employer or Authorized Representative
Name of Employer or Authorized Representative
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Document Number (if any)
Document Title
Name
First Name
Last Name
Date of Rehire (if applicable) New Name (if applicable) Last Name (Family Name) Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Name
First Name
Last Name
ZIP Code
State
Please Select
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
CAN
MEX
Address
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Name
First Name
Last Name
Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Signature of Preparer or Translator
ZIP Code
State
Please Select
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
CAN
MEX
Address
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Name
First Name
Last Name
Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Signature of Preparer or Translator
ZIP Code
State
Please Select
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
CAN
MEX
Address
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Name
First Name
Last Name
Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Signature of Preparer or Translator
ZIP Code
State
Please Select
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
CAN
MEX
Address
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Name
First Name
Last Name
Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Signature of Preparer or Translator
Name
First Name
Last Name
Employer's Business or Organization Address, City or Town, State, ZIP Code
Employer's Business or Organization Name
Today's Date (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Today's Date (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Signature of Employer or Authorized Representative
Last Name, First Name and Title of Employer or Authorized Representative
Additional Information
Check here if you used an alternative procedure authorized by DHS to examine documents.
List C
List B
List A
Today's Date (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Signature of Employee
*
Foreign Passport Number and Country of Issuance
Foreign Passport #
Form I-94
4. An alien authorized to work until (exp. date, if any)
/
Month
/
Day
Year
Date
USCIS A #
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.
4. An alien authorized to work until (exp. date, if any)
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.
*
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
Employee's Email Address
*
example@example.com
SSN
*
Date of Birth (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
ZIP Code
*
State
*
Please Select
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
CAN
MEX
Apt. or NA
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal/Zip Code
Middle Initial (if any)Other Last Names Used (if any)
Name
*
First Name
Other Last Name or NA
Last Name (Family Name)
W4 With Employer Info
Submit
Should be Empty: