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signed by employee.)
Name: Last First Middle Birth Name

Address: City State ZIP Code

Date of Birth: Social Security #

I attest, under penalty of perjury, that I am (Check one):

___1. A citizen or national of United States.

___2. An alien lawfully admitted for permanent residence (Alien Number A
_______________________________________________ ___
3. An alien authorized by the immigration and Naturalization service to work in the
U.S. Alien Number A _____________________
OR Admission Number ___________________expiration of Employment
authorization, if any ___________________________.
I attest, under penalty of perjury, that documents that I have presented as evidence of identity and
employment eligibility are genuine and related to me. I am aware that federal law provides for
imprisonment and /or fine for any false statements or use of false documents in connection with
this certificate.
Signature: Date (Month/Day/Year:

PREPARER/TRANSLATOR CERTIFICATION (To be completed if prepared by person other than

the employee.) I attest under penalty of perjury, that the above was prepared by me at the request of
the named individual and is based on all information of which I have any knowledge.
Signature: Name (Print or Type)
Address: City: State: Zip Code:

2. EMPOLYER REVIEW AND VERIFICATION: ( To be completed and signed by employer.)

Examine one document from List A and check the appropriated box, OR examine one
document from list B and one from List C and check the appropriate boxes. Provide the
Document Identification Number and Expiration Date for the document checked.
List C (documents that Establish Identity List B (Documents that Establish Identity) List C (documents that Establish Employment
And Employment eligibility Eligibility
___1. A State-issued driver’s License or a
1. U.S Passport state issued I.D. with a photograph ___1. Original social Security Number
2. Certificate of U.S. Citizenship or information including name, sex, date Card (other than a card stating it is not
3. Certificate of Naturalization of birth, height, weight, and color of Valid for employment)
4. Unexpired foreign passport with attached eyes.
Employment Authorization (Specify State) __________________ ___2. A birth certificate issued by State,
5. Alien Registration And with photograph County, or municipal Authority bearing
DOCUMENT IDENTIFICATION ___2. U.S. Military Card A seal or other certification.
___3. Other (Specify document and issuing
EXPIRATION DATE (if any) authority) ___3. Unexpired INS Employment
Authorization Specify form
#____________________________________ #___________________________________
EXPIRTAION DATE__________________ #___________________________________
CERTIFICATION: I attest, under penalty of perjury, that I have examined the documents
presented by the above individual, that they appear to be genuine and to relate to the individual
name, and that the individual, to the best of my knowledge, is eligible to work in the U.S.
Signature: Name: Title:
Employer Name: Address: Date:
Please fax to NY Nanny Center at 212-265-3361

KLM Search Services


In connection with my application for employment with you, my prospective employer, I

understand that investigative background inquires are to be made on myself, which may
include information from various state and other agencies that maintain records
concerning my past activities relating to my credit history, my driving history, my
criminal conviction history, and general public records history.
I hereby authorize, without reservation, any party or agency contracted by you, or agents
thereof, to furnish the above-mentioned information.
I hereby consent that information obtained on myself, if I am hired, will be accessible
through you by future companies to which I might apply.
I further acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as
valid as the original.
According to the Fair Credit Reporting Act, I am entitled to know if employment is
denied because of information obtained by you from a consumer reporting agency or
source of information.
PRINT NAME: _________________________________________________________
Alias (e.g. maiden name)____________________________________________
SOCIAL SECURITY NUMBER: ____________________DATE OF BIRTH:________

ADDRESSES: Past 5 Years (use additional sheet if more than 3 addresses)

CURRENT ADDRESS:______________________________________________
PRIOR ADDRESS: _________________________________________________
CITY/STATE/ZIP CODE:______________________________________
PRIOR ADDRESS: _________________________________________________
CITY/STATE/ZIP CODE:______________________________________

DRIVER’s LICENSE: (Past 5 Years)

CURRENT LICENSE NO. _____________________STATE OF ISSUE ______
PRIOR LICENSE NO. ________________________STATE OF ISSUE_______
PRIOR LICENSE NO.________________________STATE OF ISSUE _______

APPLICANT’s SIGNATURE: ______________________________________________

PROSECTIVE EMPLOYER: ___________________________DATE: ______________