Thank you for your inquiry.
Please note that any information you provide with this form is already public information. However, as an E-Verify Employer Agent certified by the DHS (Department of Homeland Security), we are bound by the Department's rules on privacy. No information, public or not, provided to us has been, or will be shared with any other person or entity.

NOTE: this questionnaire is internet secure - it cannot be read by outside sources

Company Name
NUMBER OF EMPLOYEES (approximate)
EIN (Federal Employer Identification Number - not state number)
PRINCIPAL CONTACT (Makes major company decisions - appoints hiring administrator)
COMPANY ADDRESS 2
CITY
COUNTY OR PARISH (Not countRy)
STATE
ZIP
DOES OR WILL YOUR COMPANY CONTRACT WITH THE FEDERAL GOVERNMENT (answer "Yes" or "No)
DOES OR WILL YOUR COMPANY CONTRACT WITH THE STATE OVERNMENT (answer "Yes" or "No)
DOES OR WILL YOUR COMPANY CONTRACT WITH YOUR LOCAL GOVERNMENT (answer "Yes" or "No)
HOW DID YOU LEARN ABOUT OUR SERVICE
DBA (if different than above)
COMPANY ADDRESS 1
TITLE OF ABOVE PRINCIPAL CONTACT (e.g. President, Owner, Etc.)
MAIN PHONE NUMBER
EMAIL ADDRESS
Submit
Hal Netkin is certified by the E-Verify division of the DHS (Dept of Homeland Security) as an E-Verify Employer Agent. You may verify our firm's good standing with E-Verify by calling 1-888-464-4218. Hal Netkin's E-Verify user name is HNET1531

After submitting this form to me, the DHS will tentatively approve your registration pending your agreement with an MOU (Memorandum Of Understanding) which I will email to you shortly along with further instructions.

To complete the registration process after filling the fields, press the "SUBMIT" button