Employment Eligibility Verification

EMPLOYMENT ELIGIBILITY VERIFICTION (Form I-9)

EMPLOYEE INFORMATION AND VERIFICATION: (To be completed and signed by employee.) Name: Last Address:

First

Middle

Birth Name

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: Address:

Name (Print or Type) State:

City:

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 And Employment eligibility 1. 2. 3. 4.

U.S Passport Certificate of U.S. Citizenship Certificate of Naturalization Unexpired foreign passport with attached Employment Authorization 5. Alien Registration And with photograph DOCUMENT IDENTIFICATION EXPIRATION DATE (if any)

List B (Documents that Establish Identity) ___1. A State-issued driver’s License or a state issued I.D. with a photograph or information including name, sex, date of birth, height, weight, and color of eyes. (Specify State) __________________ ___2. U.S. Military Card ___3. Other (Specify document and issuing authority) DOCUMENT IDENTIFICATION #____________________________________ EXPIRTAION DATE__________________

List C (documents that Establish Employment Eligibility ___1. Original social Security Number Card (other than a card stating it is not Valid for employment) ___2. A birth certificate issued by State, County, or municipal Authority bearing A seal or other certification. ___3. Unexpired INS Employment Authorization Specify form #___________________________________ DOCUMENT IDENTIFICATION #___________________________________ 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: Employer Name:

Name: Address:

Title: Date:

Please fax to NY Nanny Center at 212-265-3361

KLM

Search Services PRE-EMPLOYMENT INQUIRY RELEASE

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:______________________________________________ CITY/STATE/ZIP CODE: ______________________________________ 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: ______________ Inquiry