Name *
E-mail Address *
Middle name
Last name
Address
City
State
zip code
How long at this address?
Home phone number
Please list all adults who currently live with you at the address above.
Cell phone
email address
Previous address, city, state & zip code (necessary for background check)
How long at this address?
Social security number
Driver's License number
Date of birth
Marital status
Single
Married
Separated
Divorced
Widowed
Do you have any children? If yes, list their ages.
Do any of your minor children live with you?
If your children are young, who would be responsible for them while you are at work?
In which other countries have you lived before?
What is your immigration status in the United States?
Citizen
Resident
Work Permit
Other
What type of position are you applying for?
What best describes the hours you are available?
Full time
Part time
Temporary
On call
Which arrangement are you available for?
Live in
Live out
Either live in or live out
Weekends only
Other
Previous employment. (These should include childcare, housekeeping or other domestic employment only. All references will be contacted and verified.)
Name of last employer
Job title
City & State
Phone number
Cell phone
Check one
From what year to what year where you employed here?
Starting salary
Ending Salary
Reason for leaving
Describe your responsibilities there. (If you were a nanny, please include the ages of the children that were in your care.)
Name of employer
Job title
City & State
Phone number
Cell phone
Check one
Full time
Part time
Temporary
From what year to what year where you employed here?
Starting salary
Ending Salary
Reason for leaving
Describe your responsibilities there. (If you were a nanny, please include the ages of the children that were in your care.)
What languages do you speak?
What is your level of education?
Do you know how to swim?
Yes
No
Do you have your own car?
What is the name of the automobile insurance company that insures your vehicle?
What is the make,model & year of your car
Can you transport children in your car?
Yes
No
Do you smoke?
Yes
No
Do you have any contagious diseases?
Yes
No
Do you suffer from mental illness or depression?
Yes
No
Any current or past problems with drugs or alcohol?
Yes
No
Are you currently taking medication for any reason?
Yes
No
If yes, please list here.
Do you have any preference to the age of the children you would have in your care? Please describe.
Are you pet friendly
Yes
No
Do you have any known allergies to pets?
Yes
No
Are you okay with working in a home that has inside pets?
Yes
No
Have you ever been arrested in the U.S. or in any other country?
Yes
No
Days and times that you are available to work.
Have you ever been involved in any incidence of domestic violence?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is the salary range you expect to receive?
By submitting this form, you are consenting to a full background search and deem the information contained herein to be true and correct.
Please select the name of the coordinator that assisted you regarding this application. *
How did you hear about our agency?
