REFERENCE VERIFICATION ORDER FORM
All information you provide is considered completely confidential and will
not be released to any third party or organization without your written consent.
Please fill out and submit one form for each individual reference you need verified.
ORDER: You may copy and paste the following order form into an email, cut it out and fax it to the number
listed below, or send it by regular U.S. mail to the address indicated.
Phone: (952) 697-3663
L.D.A. Enterprises, Ltd. Fax:
1660 South Hwy 100, Suite 500
St. Louis Park,
All information you provide is considered completely
confidential and will not be released to any third party or organization without your written consent.
Your Personal Information:
Name (Mr. or Ms.):
State: ________ Zip Code: ___________
Home Phone: ________________ Business Phone: _________________ Fax: _________________
candidate’s personal information:
Name of the
nanny/caregiver candidate: ________________________________________________________
Social Security or ID number of the
nanny/caregiver candidate (if available): __________________________
Current Address of the nanny/caregiver candidate: _______________________________________________
State: _____________ Zip Code: _______________
Home Phone of the nanny/caregiver candidate: _________________________
Agency (only if referred through an agency):
Agency Name: __________________________________________________________
Agency Phone: ____________________
City: _______________________________ State: ___________ Zip Code: _____________
Contact Name: _______________________
Contact Title: ___________________________
Please fill out the following information for each reference you wish checked
The nanny/caregiver candidate’s employer contact information:
head of house: Mr. _________________________________________________
_______________________ Email address: ______________________
Female head of house: Ms.
or Mrs. _________________________________________
Work Phone: _______________________ Email address: ____________________
Home Phone: ________________________
of children cared for: ______________________
What were the dates of the nanny’s employment: from ______________ to: _______________
she still employed? If not, why did the nanny leave her last employer?
By your signature below you acknowledge that you have read
and agree to the policies and stipulations as published on our Reference Checking Policies and Stipulations
webpage and authorize The Reference Clinic and its employees or agents to contact the above named nanny employment
references and/or referring agency. You agree that we are not responsible for any inaccurate, untruthful, or misleading
information conveyed by the individuals providing references nor are we responsible for conducting criminal background investigations.
Therefore, you agree to release and hold harmless The Reference Clinic and its employees or agents for damages done,
theft committed, or any other adverse consequence resulting from a decision to hire any individual(s) based upon information
contained in our reference investigation report. Although we do our best to provide timely information and in most cases
can provide a completed report within 7 business days from the time we receive your order, you agree that The Reference
Clinic cannot give any guarantees regarding the exact time frame in which results can be provided. However, under
any circumstances we will complete our report with 2-weeks of the receipt of your prepaid order. You further agree that
fees paid are not subject to refund once a reference investigation has been initiated.
Order Information – please select your service:
comprehensive nanny/caregiver reference investigation - $179.95
(Agency reference investigations
are conducted at the same price)
Two or more comprehensive nanny/caregiver reference investigations
- $174.95 each
Quantity ordered ___________
Total amount: $__________
- Unless otherwise requested, reports will be emailed to your provided email address and a hardcopy
will follow by 1st Class U.S. mail if requested.
and support fees (applies to all reference checking investigations). Fees for other services appear on
our ReferenceClinic.com home page and include expert witness testimony and deposition charges.
The following charges are in addition to all fees quoted above. Please
check applicable boxes.
Faxed reports - $15.00 per report
Reports by telephone - not available
Notarized affidavits sent by U.S. mail - $15.00 per report
Canadian reference investigation report - $15.00 per report Telephone depositions - $250 per hour (1-hour minimum) Expert witness testimony or in-person depositions -
$1,850 per day, per person attending (one-day minimum) Plus all applicable expenses.
Total cost of optional services (if any)
including optional services
check one: Visa ____ MasterCard ____ American Express ____ Check ____
number: __________________________________ Expiration date: ____________
card security code ________ (last 3 numbers on the back of your Visa or MasterCard typically on the right
hand side of the signature strip) or (the 4 number code on the front of the American Express Card,
on the right hand side just above your card number.)
Name (exactly as it appears on the card): _________________________________
Billing address of the cardholder: __________________________________________________
City: _________________________ State: __________ Zip Code: ________________
Signature: ____________________________________ Date: _______________________
You may pay check, Visa/MasterCard, or American Express.
If you are paying by check, your check and authorization form (this form) should be signed and mailed to the address below.
If paying by credit card, you may also email or fax the completed and signed forms to our secure fax line: (952) 697-3667,
attention Edna Campbell.
Parkdale Plaza, 1660 South Highway 100, Suite 500
Louis Park, MN 55416
Attention: Edna Campbell