Employment Eligibility Verification

Maria S DSouza MS MD · 13803 Madera Run Parkway #604, Humble, TX 77346

Instructions — Section 1 (Employee)

Complete and sign this form on or before your first day of employment. You must present acceptable documents to your employer within 3 business days of your start date. Anti-discrimination notice: It is illegal to discriminate against work-authorized individuals.

Section 1 — Employee Information and Attestation

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 Email Address

Employee's Telephone Number

Citizenship/Immigration Status *

I attest, under penalty of perjury, that I am (check one of the following boxes):

A citizen of the United StatesA noncitizen national of the United States (See instructions)A lawful permanent resident (Alien Registration Number/USCIS Number)An alien authorized to work until (expiration date, if applicable)

Attestation

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 this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Print Full Name *

Today's Date

Employee Signature *

Sign here

Draw your signature above

Section 2 — Employer or Authorized Representative Review and Verification

To be completed and signed by employer or authorized representative. Employers must complete Section 2 within 3 business days of the employee's first day of employment. 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.

← Back to Form 2Next: Form 4 — W-4 Withholding →