i9 Town's End Stillhouse & Grill

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address

Street Address City 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

(expiration date, if applicable, mm/dd/yyyy): 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

Form I-94 Admission Number

Foreign Passport Number

Country of Issuance:

Employee

Date