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) - or NONE if no employees yet
EIN (Federal Employer Identification Number - not state number)
PRINCIPAL CONTACT (Makes major company decisions - appoints hiring administrator)
MAILING ADDRESS IF DIFFERENT THAN ABOVE: INCLUDE: STREET ADDRESS or PO BOX, CITY, STATE, ZIP
COUNTY OR PARISH (Not countRy)
DOES OR WILL YOUR COMPANY CONTRACT WITH FEDERAL GOVERNMENT (answer Yes, No, or Not Sure)
DOES OR WILL YOUR COMPANY CONTRACT WITH STATE GOVERNMENT (answer Yes, No, or Not Sure)
DOES OR WILL YOUR COMPANY CONTRACT WITH LOCAL GOVERNMENT (answer Yes, No, Not Sure)
HOW DID YOU LEARN ABOUT OUR SERVICE
DBA (if different than above)
COMPANY PHYSICAL ADDRESS: INCLUDE: STREET ADDRESS, CITY, STATE, ZIP CODE
TITLE OF ABOVE PRINCIPAL CONTACT (e.g. President, Owner, Etc.)
EMAIL ADDRESS
MAIN PHONE NUMBER
FAX NUMBER
Submit
Hal Netkin is certified by the E-Verify division of the DHS (Dept of Homeland Security) as an E-Verify Employer Agent.

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