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pdfDEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement
ICE MUTUAL AGREEMENT BETWEEN GOVERNMENT AND EMPLOYERS (IMAGE)
SELF-ASSESSMENT QUESTIONNAIRE
OMB No. 1653-0048
Expiration 12/31/2013
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 U.S. Immigration and Customs Enforcement (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]. (If more space is needed, use the Continuation Page.)
A. Company Information
1. Legally Registered Company Name / DBA
2. Company Address (Street Address, Suite Number, City, State, and 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 the list, please type it in.)
Yes
9. Number of
Employees
No
10. Secretary of State Business ID Number
11. Where are you registered?
12. Are you a subsidiary?
Yes
13. If yes, identify your parent company.
No
14. Where is your parent company located?
(if not on the list, please type it in.)
Country
15. Does your company own any subsidiaries? If yes, list below.
Company Name
EIN
1.
2.
3.
4.
16. Are you profit or non-profit?
Profit
Non-Profit
ICE Form 73-028 (03/13)
17. Does your company handle hazardous materials?
Yes
No
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18. Would your subsidiaries like to be considered for IMAGE membership? If no, explain.
(A separate application must be provided for each subsidiary.)
Yes
No
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
former INS?
Yes
No
3c. Has your company ever been served a Notice of Unauthorized Aliens letter issued by ICE
or the former INS?
Yes
No
3d. Has your company ever been served a Notice of Technical and Procedural Failures letter issued by ICE
or the former INS?
Yes
No
3e. Has your company ever been served a Notice of Discrepancies letter issued by ICE or the former INS?
Yes
No
B. E-Verify and Social Security Number Verification Service (SSNVS) Participation
1. E-Verify Participant?
Yes
3. Date Enrolled
5. SSNVS User ID Number
6. Date Enrolled
No
4. SSNVS Participant?
Yes
2. E-Verify Identification Number
No
C. Self-Assessment Questionnaire (SAQ) (Attach additional sheets, if necessary.)
ICE Form 73-028 (03/13)
Page 2 of 9
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, the Department of Justice Office of Special Counsel
(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
ICE Form 73-028 (03/13)
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10. When in the hiring process does your company introduce and complete Form I-9 for new employees?
11. Are you using the current version of 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 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 be available for inspection within 3 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 reverification?
20. Does your company conduct internal audits of your Forms I-9?
ICE Form 73-028 (03/13)
Page 4 of 9
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 Social Security Number discrepancies identified by a federal or state government
agency?
24. Describe all Form I-9 and/or counterfeit document detection training your company has received in the past 3 years.
ICE Form 73-028 (03/13)
Page 5 of 9
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 your answer is not on the list, please type it in.)
Please provide any additional information that you think would be beneficial to ICE in evaluating your
application for IMAGE membership:
ICE Form 73-028 (03/13)
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D. Attachments
Provide copies of the following documents as attachments to this application (if applicable):
(Check box if document is attached.)
Organizational chart and related department descriptions
List of all locations with employees, including 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
SSNVS results page
Company profile
DOJ/OSC complaints
Social Security Administration (SSA) Employee Correction Requests (no-match letters) for the past 3 years
Final Order issued by ICE or the former INS for violation of Section 274A of the 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's Address (Street Address, Suite Number, City, State, and Zip Code)
3. Primary POC's Telephone
4. Primary POC's Facsimile
5. Primary POC's E-Mail
ext.
6. Alternate POC (Name and Title)
7. Alternate POC's Address (Street Address, Suite Number, City, State, and Zip Code)
8. Alternate POC's Telephone
9. Alternate POC's Facsimile
10. Alternate POC's E-Mail
ext.
Name and title of individual completing the application
Business Phone Number
Date Completed
END OF IMAGE SELF-ASSESSMENT QUESTIONNAIRE
Member ID Number
ICE Form 73-028 (03/13)
Page 7 of 9
Continuation Page
ICE Form 73-028 (03/13)
Page 8 of 9
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 Office of Management and Budget Control Number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to:
Office of the Chief Financial Officer/OAA/Records Management Branch
U.S. Immigration and Customs Enforcement
500 12th Street, S.W., STOP 5705, Washington, D.C. 20536-5705
(Do not mail your completed application to this address.)
ICE Form 73-028 (03/13)
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| File Type | application/pdf |
| File Modified | 2013-03-05 |
| File Created | 2013-03-05 |