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Last Name

Middle Initial

First Name

Other Last Names (if any)

State

Address Street Number and Name

City or Town

ZIP Code

Apt Number

Employees Telephone Number

Employees Email Address

Date of Birth mm/dd/yyyy

First 3 of social

middle 2 of social

last 4 of social

1 A citizen of the United States (use an x)

2 A noncitizen national of the United States (use an x)

Alien Registration NumberUSCIS Number 1

3 A lawful permanent resident (use an x)

Alien Registration NumberUSCIS Number 2

4 An alien authorized to work (use an x)

1 Alien Registration NumberUSCIS Number OR

2 Form I94 Admission Number OR

3 Foreign Passport Number

Country of Issuance

Signature

Todays Date mmddyyyy

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