I-9 Certification issued by the CT Department of Labor

This certifies that the Connecticut Department of Labor has complied with the requirements of section 274A(b)
of the Act concerning verification of the identity and employment eligibility of the individual referred, and has
determined that, to the best of this agency’s knowledge, the individual listed below is authorized to work in the
United States.

Worker’s Name/Address
______________________________________________
______________________________________________
______________________________________________

Signature of person being referred to job opportunity _____________________________

(Must be signed in the presence of the employer)

Worker’s Date of Birth _________________________

Employer’s Name/Address
______________________________________________
_____________________________________________
______________________________________________

Job Order # ___________________ Type of Work ___________________________________

Document Title_______________________________ Document # __________________________________

Expiration Date ________________________________

Document Title_______________________________Document # __________________________________

Expiration Date ________________________________

Restriction Information ________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________
Signature of Official from the Connecticut Department of Labor _____________________
Certification issued on ______________________

Counterfeiting, falsification, unauthorized issuance or alteration of this certification constitutes a violation of

federal law pursuant to title 18, U.S.C. 1546.

Employers: You are not required to verify the above-named individual’s identity or employment eligibility. Please
retain this certification for your records in lieu of Form I-9.

200 Folly Brook Boulevard, Wethersfield, CT 06109  www.ctdol.state.ct.us

An Equal Opportunity/Affirmative Action Employer