Fillable Form I-9: Employment Eligibility Verification (Fulton County Government)

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Form I-9: Employment Eligibility Verification (Fulton County Government)

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USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 11/14/2016 N
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form.
Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ
an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. 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.)
Last Name (Family Name) First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
-
-
Employee's E-mail Address
Employee's Telephone Number
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 attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 11/14/2016 N
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name)
M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine 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.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Signature of Employer or Authorized Representative
Today's Date(mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
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 a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
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
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status 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.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
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
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
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
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
8. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of Birth Abroad issued
by the Department of State (Form
FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
5. Native American tribal document
7. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
6. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 11/14/2016 N
Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
NAME:__________________________ DEPARTMENT:________________________
OFFICIAL OATH OF FULTON COUNTY
STATE OF GEORGIA
I, ___________________________________, do solemnly swear that I will well and
truly discharge the duties of ___________________________ for Fulton County, in all
matters which require my official action, to the best of my knowledge and skill, and I will so
act as in my judgment will be most conducive to the welfare and best interests of the entire
county.
I do further solemnly swear and affirm that I am not the holder of any public money
due this State unaccounted for; that I am not the holder of any office of trust under the
Government of the United States (except Postmaster), nor of either of the several states, nor
of any foreign State, and that I am otherwise qualified to hold said office, according to the
Constitution of the United States and Laws of Georgia, and that I will support the
Constitution of the United States and of this State.
__________________________________
(Signature of Affiant)
Sworn to and subscribed before me this
____ day of __________________ , 2019.
__________________________________
Signature and Title of Officer
Authorized by Law to Administer Oaths
FULTON COUNTY, GEORGIA
SECURITY QUESTIONNAIRE
(Required by Georgia Laws No. 904, 1974 Session Page 411)
INSTRUCTIONS: Prospective employee completes the form in the number of copies
required by the Appointing Authority and the latter forwards the original to the Department
of Human Resources with initial notification that the individual is to be employed. Fill in all
items, if additional space is required, continue under item 6 or attach additional sheets.
1. Department ______________________________________________________________
2. Name ___________________________________________________________________
(Last Name) (First) (Middle)
Other names used: (maiden name, names by former marriages, former names
changed legally or otherwise, aliases and nicknames. Specify which and show dates
used.)
_________________________________________________________________________
_________________________________________________________________________
3. Address__________________________________________________________________
(Street & No.) (City) (State) (Zip Code)
4. (a) Are you now or have you been within the last ten (10) years a member of any
organization which to your knowledge at the time of membership advocates or has as
one of its objectives, the overthrow of the government of the United States or of the
government of the state of Georgia by force or violence?
Yes ___ No___ If “Yes”, state the name of the organization and your past and present
membership status including any offices held therein.
_________________________________________________________________________
_________________________________________________________________________
(b) If the answer to (a) is “Yes” and the employing authority deems further inquiry
necessary, you will be notified of such determination. No action adverse to your
application will be taken because of an affirmative answer until after such an inquiry,
with notice to you and an opportunity for you to present evidence, and only if the
result of such inquiry brings your application within the prohibition within the
Sedition and Subversive Activities Act of 1953.
5. (a) Have you ever been convicted or are any charges now pending against you, by
Federal, State or other law-enforcing authority, for any violation of any federal law,
state law, county or municipal law, regulation, or ordinance? (Do not include
anything that happened before your sixteenth birthday. Do not include minor traffic
violations for which a fine of $35 or less was imposed. (All other convictions must be
included even if they were pardoned.)
Yes _____ No _____
(OVER)
(b) If the answer to (a) is “Yes”, state the reason convicted, the date convicted, and the
place where convicted. ______________________________________________________
__________________________________________________________________________
6. Space for Continuing Answers or Explanations: (Show item Number to Which answers
or explanations apply. Attach separate sheet(s) if more space is needed.)

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
NOTE: Before signing this form, check all answers and explanations to see that you have
answered all questions fully and correctly. This form is to be executed under oath, subject to the
penalties of false swearing in accordance with the provisions of the Georgia Laws 904, 1974
Session Page 411.

AFFIDAVIT OF VERIFICATION
Georgia _________________ County
Personally appeared before the undersigned attesting officer, duly authorized to
administer oaths _____________________________________________, who, after being duly
sworn, deposes and says and declares under penalties of false swearing that he/she is the person
who executed the foregoing instrument, that he/she has read and completed the same and knows
and understands the contents thereof; that the matters stated therein and the answers and
information furnished by him/her in the foregoing questionnaire, including any attachments, are
true and correct.
_________________________________
Signature of Affiant
SWORN TO AND SUBSCRIBED BEFORE ME
This _______ day of ________________________, 2019.
_______________________________________________
Notary Public
County of _____________________ My commission expires _____ day of _______ , 20____ .
(Affix Seal)
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Form I-9: Employment Eligibility Verification (Fulton County Government)

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Completed 17 July 2020

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