Summer MCAT Preparation Program - University of Utah - School of ...

University of Utah School of Medicine
Summer MCAT Preparation and Research/Clinical Training Scholars Program
Employment Eligibility Verification
Section1. Employee Information and Verification (All participants in this program are hired by the University of Utah to work
as temporary, part-time employees.)
Name ________________________________________________________________________
Address ______________________________________________________________________
City, State Zip Code ____________________________________________________________
Telephone Number ( ) ______________________________________________________
Date of Birth __________/__________/__________
Social Security 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):
A citizen or national of the United States
A Lawful Permanent Resident (Alien # A _________________________)
An alien authorized to work until __________/__________/__________
(Alien # or Admission # _______________________________________)
Signed _____________________________________________ Date _____/_____/_____