Nanny Brokers Background Check Registration Form
INFO REQUESTED ON THE FOLLOWING PERSON:
Caregivers Complete Name ____________________________________________________
Current Address___________________________________________City____________State_____
Zip____________ Date Of Birth___________________ Social Security #_______________________
Name On Drivers License________________________________ Dr Lic #________________________
State of Issue_______________________
Expires________________
Family Requesting Info
Name ___________________________________________________
Address____________________________________________City___________State_____
Zip_____________________________ Phone ______________________Fax_______________
Have you obtained a signed Consent Form?____________ If NO please go to our website and print one before
going further. (Applicant Must Sign before going further)
How did you locate this person?______________________________________________________
Have you met them in person?__________________________________
Nanny Brokers USA has been contracted by you the prospective employer to conduct a verification of
information in your employment application/confidential job offer or other information provided by you. The
information requested below in this form is required by nanny Brokers USA to complete this verification.
THE INFORMATION BELOW IS NOT PART OF YOUR EMPLOYMENT APPLICATION.
The sole purpose of the information requested below is for verification of information provided by you or
statements made by you.
Please carefully complete all of the requested information.
A copy of Summary of Rights under the fair Credit Reporting Act is attached.
Important: The information contained in this Applicant Verification Report is provided for identity verification
and fraud prevention purposes only. It does not constitute a consumer report as defined by Fair Credit
Reporting Act (FCRA). This report is not intended to recommend, or not recommend, any individual and it
should not be used as a factor in evaluating the named individual for employment, promotion, reassignment or
retention as an employee. The records may or may not have sufficient information to conclusively establish the
exact identity of an individual. The information is provided merely as an indication of information that should be
verified prior to making a decision. Final verification of the named individual's identity is solely your responsibility.
Parent Signature ____________________________________________ Date____________________
If you would rather contact us by phone please call our office at (678) 380-7158
Fax after 6 PM to (678) 380-7158