Employee Information and Xxxxxxxxxxxx Sample Clauses

Employee Information and Xxxxxxxxxxxx. Xx be completed and signed by employee at the time employment begins. Print Name: Last First Middle Initial Maiden Name Address (Street Name and Number) Apt. # Date of Birth (month/day/year) City State Zip Code Social Security # 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 per jury, that I am (check one of the followin A citizen or national of the United States A Lawful Permanent Resident (Alien # A An alien authorized to work until / / (Alien # or Admission #) g): Employee's Signature Date (month/day/year)