Please PRINT & FILL-OUT New-Hire Request Form. Send to:
(fax) 904-269-0850 or (e-mail) form@kensingtonnanny.com / mail to main offices
Questions? Call 904-264-3626 Toll-free 1-866-40-NANNY

New-Hire Screening Request Form

Personal Information of New-Hire

Date:________________

New-hire Information:
First Name: __________________________ MI ______ Last Name:________________________________

Maiden Name (if any): ___________________________

Current Address:_____________________________Apt______City________________ST______Zip________

Previous Address:____________________________Apt______City________________ST______Zip________

Date of Birth: _____/_____/_____  

SSN: ______-_____-______ DL#_________________________________________ ST____

List all States/Countries in which the New-hire has lived:___________________________________________
_____________________________________________________________________________________

Type of Screening Requested:
Background Check:  Local_____   State_____   National_____   International _____
Department of Motor Vehicles:  Yes_____   No_____
SSN Verification: Yes_____   No_____
National Aliases: Yes_____   No_____
National Sexual Offenders/Predators:  Yes_____   No_____
Drug-screening: Yes_____   No_____
Physical Exam: Yes_____   No_____

Family Information
Name: __________________________________________________________________________________
Address: _______________________________ City:_________________ State: _____ Zip Code:________
Home Telephone: (          ) __________-________________    
Mobile Telephone: (          ) __________-_______________

New-hire Acknowledgement
I promise that the information provided to my prospective/new employers is true and correct. I agree to have
Kensington Nanny & Home Services perform a background check for me. I will provide the complete and full
results of my background check to my prospective/new employers. I also give permission for Kensington
Nanny & Home Services to release my complete and full results to my prospective/new employers.

New Hire Name (print):________________________________________________________________

New Hire Signature: _____________________________________________ Date: ________________

Family Acknowledgement
By signing below, the Family has received permission from the new-hire for the new-hire background check to
be performed.

Family Name (print):_____________________________________________________________________

Family Signature: _______________________________________________________________________

Please return New-hire Screening Request Form to:
(fax) 904-269-0850 or (e-mail) form@kensingtonnanny.com
Questions? Call 904-264-3626 Toll-free 1-866-40-NANNY