Instructions for Completing Section 1 (please review carefully)

1. Enter your full legal

name. For two last
names or hyphenated
last name, include
both names in the last
name field.

2
3

2. Provide all other

names used, may
include maiden name.
Enter N/A if no other
legal names used.
3. Enter street
address. Address may
not be a P.O. Box.

7
4. Enter Date of Birth
in mm/dd/yyyy format.

5. Enter Social
Security number.
Required for E-Verify
states.
6. Entering email
address and
telephone number is
optional. If you
choose not to
disclose, enter N/A.

9. Leave this section blank unless

preparer or translator filled out form on
your behalf. Preparer or translator must
certify he/she assisted you by completing
this certification section.

7. Check appropriate
box. If you select
alien authorized to
work, ensure ANumber or USCIS # or
Form I-94 Admission
Number and passport
information is
provided.
8. Sign and date the
form using current
date and date format
mm/dd/yyyy. Must be
completed no later
than first day of
employment.