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Department of Homeland Security
U.S. Immigration and Customs Enforcement
IMAGE MEMBERSHIP APPLICATION
OMB No. 1653-NEW
Expires XX/XX/XXXX
Form Instructions: Please complete all items on the application. Once completed please return the application and any attachments via e-mail
or hard copy delivery to the ICE IMAGE Coordinator who originally contacted you. No personal information about individual employees should
be included in the application or any attachments. Questions regarding the application, or the IMAGE Program can be submitted to
[email protected].
A.
Company Information
1. Legally Registered Company Name / DBA
2. Company Address (Street Address, Suite Number, City, State & Zip Code)
3. Mailing Address (Street Address, Suite Number, City, State & Zip Code and P. O. Box if applicable)
4. Federal Employer Identification Number (EIN)
5. Company Website
6. Federal Contractor? 7. North American Industry Classification 8. Business Structure
System (NAICS) Code
(if not on list, please type it in)
Yes
9. Number of
Employees
No
10. Secretary of State ID Number
11. Where are you registered?
12. Are you a subsidiary?
No
Yes
13. If yes, identify your parent company
14. Where is your parent company located?
(if not on list, please type it in)
Country
15. Does your company own any subsidiaries? If yes, list below
Yes
Company Name
No
EIN
1.
2.
3.
4.
16. Are you profit or non-profit?
Profit
17. Does your company handle hazardous materials?
Yes
Non-Profit
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No
ICE Form 73-028
(Rev. 09/28/2009) N
18. Would your subsidiaries like to be considered for IMAGE membership? If no, explain.
(A separate application must be provided for each subsidiary)
B.
No
E-Verify and Social Security Notification Verification Service (SSNVS) Participation
1. E-Verify Participant?
Yes
Yes
2. E-Verify Identification Number
3. Date Enrolled
5. SSNVS User ID Number
6. Date Enrolled
No
4. SSNVS Participant?
C.
Yes
No
Self- Assessment Questionnaire (SAQ) (Attach additional sheets if necessary)
1. Have your Forms I-9 ever been inspected by a federal or state entity? If yes, explain.
Yes
No
2. Has your company ever been administratively fined for violation of Section 274A of the Immigration and Nationality
Act (INA)? If yes, provide a detailed explanation and a copy of the Final Order (Form I-764).
Yes
No
3a. Has your company ever been served a Warning Notice (Form I-846) for violation of Section 274A of the INA?
Yes
No
3b. Has your company ever been served a Notice of Suspect Documents letter issued by ICE or the INS?
Yes
No
3c. Has your company ever been served a Notice of Unauthorized Aliens letter issued by ICE or the INS?
Yes
No
3d. Has your company ever been served a Notice of Technical and Procedural Failures letter issued by ICE or the INS?
Yes
No
3e. Has your company ever been served a Notice of Discrepencies letter issued by ICE or the INS?
Yes
No
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ICE Form 73-028
4. Has your company ever been the subject of an enforcement action resulting in the arrest of unauthorized workers?
If yes, explain.
Yes
No
5. Has your company ever been investigated and/or fined by the U.S. Department of Labor (DOL) or any state
labor authority? If yes, explain.
Yes
No
6. Has your company ever been investigated by ICE, DOJ/OSC, or any other law enforcement agency for criminal or
administrative violations related to your hiring practices or has a complaint ever been filed by a federal agency
against your company or representative? If yes, please explain the allegation (s) and final resolution.
Yes
No
7. Does your company have a written hiring policy?
Yes
No
8. Does your company have a written anti-discrimination policy?
Yes
No
9. Does your company have an internal training program on the hiring process? If yes, describe your
training program.
Yes
No
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ICE Form 73-028
10. When in the hiring process does your company introduce and complete the Form I-9?
11. Are you using the current version of the Form I-9 for all new hires?
Yes
No
12. Does your company provide the list of acceptable Form I-9 documents to the employee in writing? If no, describe
how your company informs the employee of acceptable Form I-9 documents?
Yes
No
13. Does your company photocopy documents presented to satisfy the Form I-9 requirement?
Yes
No
14. If you make photocopies, does your company make copies for all new hires?
Yes
No
15. If you make copies, are those copies attached to and made a part of the Form I-9?
Yes
No
17. Are your Forms I-9 kept separate from other employee documents?
Yes
No
18. If provided notice, would your Forms I-9 available for inspection within three business days?
Yes
No
Yes
No
16. How do you retain your Forms I-9? (choose one from the list)
19. What is your company's procedure for tracking those Forms I-9 requiring employment re-verification?
20. Does your company conduct internal audits of your Forms I-9?
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ICE Form 73-028
21. Does your company have a review process for suspected fraudulent documents or instances of suspected identity
theft? If yes, describe the process.
Yes
No
22. Does your company have an established policy that encourages employees to report suspected unauthorized aliens
or other criminal activity within the workforce? If yes, describe your internal reporting mechanism and the
procedure for resolving those reports.
Yes
No
23. What is your company's policy for resolving SSA Employee or Employer Correction Requests ?
24. Describe all Form I-9 and/or counterfeit document detection training your company has received in the past three years.
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ICE Form 73-028
25. Describe any E-Verify training that your company has received.
26. If you are an E-Verify participant, have you posted a notice informing employees of your participation?
Yes
No
27. If you are an E-Verify participant, have you posted the DOJ/OSC anti-discrimination notice?
Yes
No
28. Does your company utilize contractors?
Yes
No
29. Does your company review the hiring practices of your contractors? If yes, describe the review process.
Yes
No
30. How did you hear about IMAGE? (if answer is not on list, please type it in)
Please provide any additional information that you feel would be beneficial to ICE in evaluating
your application for IMAGE membership:
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ICE Form 73-028
D.
Attachments
Provide copies of the following documents as attachments to this application (if applicable):
(Check box if document attached)
Organizational chart & related department descriptions
List of all locations with employees, to include: the number of employees at each location; if hiring is conducted at that location; and
whether Forms I-9 are retained at that location
List of all employees with Form I-9 certification authority
Current employee application packet(s)
Articles of Incorporation
Hiring policy
Anti-discrimination policy
E-Verify summary report
Social Security Number Verification Service (SSNVS) results page
Company profile
U.S. Department of Justice, Office of Special Counsel (DOJ/OSC) complaints
Social Security Administration (SSA) Employee Correction Requests (no-match letters) for the past three years
Final Order issued by Immigration and Customs Enforcement (ICE) or the Immigration and Naturalization Service (INS) for violation of
Section 274A of the Immigration and Nationality Act (INA)
List of contract company(s) used and a brief description of services provided by contractor(s)
Internal Form I-9 audit reports
E.
Contact Information (Business Information Only)
1. Primary Point of Contact (POC) (Name and Title)
2. Primary POC Address (Street Address, Suite Number, City, State and Zip Code)
3. Primary POC Telephone
4. Primary POC Facsimile
5. Primary POC E-Mail
ext.
6. Alternate POC (Name and Title)
7. Alternate POC Address (Street Address, Suite Number, City, State and Zip Code)
8. Alternate POC Telephone
9. Alternate POC Facsimile
10. Alternate POC E-Mail
ext.
Name and title of individual completing application
Business Phone Number
Date Completed
END OF IMAGE SELF-ASSESSMENT QUESTIONNAIRE
Member ID Number
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ICE Form 73-028
Privacy Act Statement
Authority: 8 U.S.C. §1324(a)
Purpose: This information will be used to (1) determine an employer's suitability to participate in the IMAGE program, and (2) develop training,
employment policies and other employment-related materials to assist employers in complying with immigration laws.
Routine Uses: The information on this form may be disclosed as generally permitted under 5 U.S.C. §552a(b) of the Privacy Act of 1974, as
amended. This includes using this information as necessary and authorized by the routine uses published in the DHS/ALL-002 Mailing and
Other Lists Systems of Records (73 FR 71659, November 25, 2008).
Disclosure: The disclosure of information on this form is voluntary; however, failure to furnish the requested information may delay or prevent
employers from participating in the IMAGE program.
Public Reporting Burden. U.S. Immigration and Customs Enforcement is collecting this information as a part of its agency mission under the
Department of Homeland Security. The estimated average time to review the instructions, search existing data sources, gather and maintain the
data needed and completing and reviewing this collection of information is 90 minutes (1.5 hours) per response. An agency may not conduct or
sponsor, and a person is not required to respond to, an information collection unless it displays a currently valid OMB Control Number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:
Department of Homeland Security
U.S. Immigration and Customs Enforcement
500 12th Street, S.W., Room 3138, Washington, D.C. 20536
(Do not mail your completed application to this address.)
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ICE Form 73-028
| File Type | application/pdf |
| File Modified | 2010-09-27 |
| File Created | 2010-06-16 |