NIK IMPlOm INFORMATION FORM

rhia tofor.aUoo ifa«ll be tratt.d *• cooftdential. It it r.quir.d for fedoril start ni1
*«ForHBa*. PifiSf COMPtm All ITIKS. ' *" *
2, »«pt 3. Job T i t l e
FIRE:
TT'I'M riiMupt 7" "T r
8. ""Bac^ (Check On•)
1. Sex (Chock One)

9. Date of Birth (Tear, Month,

D fa.elo (f) K2 Male (M)
TE:
LJ Aaericafl I n d i i n / A i a t k i B Detive ( A t )
10. Merita) Statue
M B i a ^ k (B) O Hiepaalc (HIS) (W) (Check Oae) U SiofU 0) f3"*.rrt«d (2)
LJ Aei*n A n e r U a t i / P e c i f i c leleader D (4) Q S.p.r.t.d (S)

12. Cto you ap««k, r«»d, or writ* any laafusfe othar thu (»(Tl«h?
If ye». Hat what laatft>t««« ud ebtch type «nd d«|ree of fluency7

IS. Kdaotton ««rond Bich School f Attach «<fdition>l tt««t If nec«»»*rr. y

of School or C«JI»t* Oatea Attended Major Graduated Decree Credit*

m
16. ti«t any ep'eeiel lic«o§*» or e t r t i f l c t t i o a e required for your Jok cod mny other*
. 4pprej»wre, Burxyoie, a)te.—fAttach-»JUitig«Hil aheat 'if
Type of lie, or C• rt leeuo Hate ixpiretioo

11. Bo you hate the

ticeneo ----- Kxpipetion Vet.

_j (.-•

laitlala of Peparti«at
Hepre»«nt«tiv»."

MIS SICTXOB UBI8VBD fOfi PBHSOVNIt OlPAXTMJtlfT USX OMIY.

S»pior«« Number _ Adjuatod Service Bate
 Department of Homeland Security OMB No. 1615-0047; Expires 03/31/07
U.S. Citizenship and Immigration Services Employment Eligibility Verification
Please read instructions carefully before completing this form. The instructions must be available during completion
of this form. ANTI-DISCRIMINATION NOTICE: It Is Illegal to discriminate against work eligible individuals. Employers
CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of
a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins.
Print Name: First Middle Initial Maiden Name
|f
Apt. # Date of Birth (month/day/year)

Zip Code

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

I am aware that federal law provides for
pi A citizen or national of the United States
imprisonment and/or fines for false statements or
Q A Lawful Permanent Resident (Alien #) A
use of false documents in connection with the
[H An alien authorized to work until
completion of this form.
(Alien # or Admission #)
mployee's Signature

and/or TranslatoYvertification. (To be completed and signed if Section 1 is prepared by a person

other than Ihe employee.) I attest, under penalty of perjury, that I have assisted in the completion of this formand thai to the best
of my knowledge the information is true and correct.
Preparer's/Translator's Signature Print Name

Address (Street Name and Number, City, State, Zip Code) Date (month/day/year)

Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR
examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if
any, of the document(s).
List A OR List B AND List C
Document title: Cheer i
Issuing authority:

Document #:

Expiration Date (if any):

Document #:

Expiration Date (if any):

CERTIFICATION - (attest, under penalty of perjury, that I have examined the documents) presented by the above-named
employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the
employee began employment on (month/day/year) £ I ^Q^f and that to the best of my knowledge the employee
is eligible to work in the United States. (State employment agencies may omit the date the employee began employment.)

Section 3. Updating and l signed by employer.

A. New Name (tt applicable) HARTFORD, CONN. 06103 B. Date of Rehire (month/dayfyear) (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment
Document Title: Document #: Expiration Date (if any):
I attest, under penalty of perjury, that to the best of my knowledge, this employee Is eligible to work In the United States, and If the employee
presented documents), the documents) I have examined appear to be genuine and to relate to the Individual.
Signature of Employer or Authorized Representative Date (month/dayfyear)

NOTE: This Is the 1991 edition of the Form I-9 that has been rebranded with a Form 1-9 (Rev. 05/31/05)V Page 2
current printing date to reflect the recent transition from the INS to DHS and its
components.
12. SPECIAL QUALIFICATIONS AND SKILLS

A. List licenses, (include driver's license or commercial driver's license A, B or C) or

certifications which you possess for any type of work. Also list the state or other licensing
authority which granted it and applicable operator numbers and expiration dates:
GPL CJ£I&~^ IVTrtrr-TmKer
Pqnipfr-YTen"t

B. List any special skills, machines and equipment which you can operate (include typing speed
if appropriate} which may qualify you for the position for which you are applying:

J. Rm firriEtnWvt UjHh Ecr^i (ijctnla -Sble,

C. Give any special qualificatjpris,npt covered elsewhere in this application, such as (1) your
publications; (2) membership in professional organizations; (3) honors and awards received:

D. List all computer programs with which you are proficient; MS Word, MS Access, Excel, etc.:

E. Can you speak, read or write any language other than English? Yes
If Yes, indicate language and check type and degree of fluency:

Language
Speak Read Write Excellent I I Good I I Fair I I

Page 2 of 5
13. EXPERIENCE: In the spaqe provided below give a complete record of your employment over the last 10 years beginning
with your present or most recent employment Account for all periods, including self-employment, unemployment, and
military service (list type of separation). Use additional sheets if necessary. Work performed more than 10 years ago
should be noted if related to the nosition for whid>-vQii are anolvina.
May We Contact your present employer? \Y&*) NO (Note: We may contact previous employers to
v
' verify Information)

HOURSPERWE6K NAME, TTTLEAND PHONE NUMBER OF IMMEDIATE SUPERVISOR

i\ rN \t\a «^~ ^*
^rO I D^uarc »)"7Tiarv= f'jev v>j Pr

-(rr\. CT rtntti.

ENDING DATE ME AND AOBRESS OF EMPLOYER

MONTH Y

HOURS PER VKEK NAME, TITLE AND PHONE NUMB MEDIATE SUPERVISOR

REASONS FOR LEAVING

Page 3 of 5
13. EXPERIENCE: In the space provided below give a complete record of your employment over the last 10 years
beginning with your present or most re'cent erfiployfnent. Account for all periods, including self-employment,,
unemployment, and military service (list typ'e of separation). Use additional sheets if necessary. Work performed
, more than 10 years ago should be noted If rfelatedjp the position for which you are applying.
May we contact your present employer? (YE|i NO (fote: we.may contact previous employers to
verify information)
STARTING BATE ENDING DATE

MONTH \KAR 'NTH YE.

LJ •, \. yi.vx p . f, n y .r . \ * V J V-. IV l_^^>

SAWRt HOURS PER WEEK NAME, TITLE AND PHONE NUMBER OF IMMEDIATE SUPERVISOR

REASONS FOR LEAVING

r\nr •4O
YOUR PRESENT OR LAST JOB TITLE:

YOUR DUTIES.-!

m T?nd 4r> "n

*

E, TITLE AND PHONE NUMBER OF IMMEDIATE SUPERVISOR

• UAK.1 l-.»^n—I'V_M./ / \. J v ^ x. nj. i ^

NAME, TITLE AND PHONE NUMBER Of IMMEDIATE SUPERVISOR

ASONS FOR LEAVING

Kfrr

STARTING DATE

NAME, TITLE AND PHONE NUMBER OF IMMEDIATE SUPERVISOR

Page 3 of 5
13. EXPERIENCE: In the space provided below give a complete record of your employment over the last 10 years
beginning with your present or most recent eirlployment. Account for all periods, includirtg self-employment,,
unemployment, and military service (list type of separation). Use additional sheets if necessary. Work performed
. more than 10 year;: ago should be noted if related to the position for which you are applying.
May we contact your present employer? (YE&) NO (Note: We,may contact previous employers to'
>— verify Information)

STARHNG DATE ENDING DATE

MONTH YEAR MONTH

SALARY
ya i i unpix A.--J
HOURS PER WtEK
iM 1
Wlrvfor.
tn -" rafcL;—I—r-Qt—IAJ» *y;>» « PST
v -x
NAME, TITLE AND PHONE NUMBER OF IMMEDIATE SUPERVISOR

{def/om

STARTING DATE ENDING DATE E AND ADDRESS OF EMfiLOYER ,,_ _ _

MONTH YEAR
Corf).

SALARY SALARY HOURS PER WEEK NAME, TITLE AND PHONE NUMBER OF IMMEDIATE SUPERVISOR

Paae 3 of 5
13. EXPERIENCE: In the space provided below give a complete record Of your employment over the last 10 years
beginning with your present or most recent em'ployment. Account for all periods, including self-employment,,
unemployment, arid military service (list type of separation). Use additional sheets if necessary. Work performed
more than 10 years ago should be noted If related to the position for which you are applying.
May we contact your present employer? YES NO (Note! We,may contact previous employers to'
verify information)
STARTING DATE ENDING DATE

'
SALARY
Qoeentfr
HOURS PEFfWEEK
EFfWEEK N>ME,
AME, TITLE AND PHONE NUMBER OF IMMEDIATE SUPERVISOR

ASONS FOR LEAVJNQ YOUR PRESENT OR LAST JOB TITLE:

UR DUTIES:

^1

ffl- f
STARTING DATE ENDING DATE NAME AND ADDRESS OF EMPLOY!
YEAR MOUTH YEAR

SALARY SA

i^
HOURS PER WEEK NAM^ TITLE AND PHONE NUMBER OF fMMEDIATE SUPERVISOR

NS FOR LEA VING

4(3
YOUR JOB TITLE:
bfes
f /J fc /dnoer
r , .. i

Page 3 of 5
13. EXPERIENCE: In the space provided below give a complete record of your employment over the last 10 years
beginning with your present or most recent employment. Account for all periods/ including self-employment,
unemployment, and military service (list type of separation). Use additional sheets If necessary. Work performed
. more than 10 years ago should be noted If related to the position for which you are applying.
May we contact your present employer? YES NO (Mote: we may contact previous employers to
verify Information)
STARTING DATE ENDING DATE

MOIITH YEAR

<[ ol STrS
SALARY SALARY HOURS PER WEEK NAME, TITLE AND PHONE NUMBER OF7MMEDIATE SUPERVISOR

SONS FOR LEAffNG OUR PRESENT OR LAST JOB titLE:

t^mo°r
OUR Dun,*: fife

NAME, TITLE ANO PlfONE NUMBER OF IMHEDIATE SUPERVISOR __ _

STARTING DATE ENDING DATE

MONTH YEAR K n
o
c4 11 I ^t \ . C V L A J / Q ICx^ U^ » I
ffALARV SALARY" HOURS PER WEEK NXME, TITLE AND PHdNE NUMBER OF IMMEDIATE SUPERVISOR

:ASONS FOR LEAVING YOUR JOB TITLE:

OreiqNrn PfYXti^
'OURDUTIES:
DTlUi^ ;If4^ far t^e^^rW^

STARTING DATE ENDING DATE

a
MONTH YEAR MONTH

gH. MJ,
HOURS PER WEEK NAME, TITIE AND PHONE NUMBER OF IMMEDIATE SUPERVISOR
WE

Pane* 3 of fi
13. EXPERIENCE: In the space provided below give a complete record of your employment over the last 10 years beginning
wftti your present or most recent employment Account for all periods, including self-employment, unemployment, and
military service (fist type of separation). Use additional sheets if necessary. Work performed more than 10 years ago
should be noted if related to the oosfcion for which vou are aootviiKi.
May we contact your present employer? YES NO (Note: We may contact previous employers to
verify Information)

r\tjv»v/r*3 F WT\ i_c/\» irrva *.

fetf^Tfrhr^
DU
^^tteif,( ? i
YOUHOVTlESr-T}
<TPidbr fif^

STARTING DATE EN DING DATE NAME AND ADDRESS OF EMPLOYER

HONTN TEAR MONTH TEAR

SALARY SALARY HOURS PER WEEK NAME, TITLE AND PHONE NUMBER OF IMMEDIATE SUPERVISOR

REASONS FOR LEAVING YOUR JOB TITLE:

YOUR DUTIES:

Page 3 of 5