What jobs would you like to be considered (nanny, housekeeper and/or babynurse)?
First Name
Middle Name
Last Name
Address Line 1
Address Line 2
City, State, Zip
Daytime Phone (
Evening Phone (
E-mail Address
Live-in, Live-out or either?
Do you drive?
Do you own a car? If so, year & model:
Driver License #:
State Issued:
Do you swim?
D.O.B.
Do you have a valid Social Security Number?
Birthplace:
Citizenship (U.S., Green Card, Resident Alien, etc.):
How did you hear about us?
Please describe your experience in general
Most Recent Job: Name & Address
Reference Number (
Job Duties: (list ages of children if applicable)
Dates of Employment
Salary and Hours
Why did you leave or are you looking to leave?
Previous Job: Name & Address
2nd Reference Number (
Job Duties:
Dates of Employment:
Salary and Hours:
Why did you leave?
Please explain any gaps in employment?
Education #1: High school (Name, dates, location):
Education #2 College (Name, dates, location):
What is the highest level of school completed?
Minimum salary you would interview for?
Please list your availability (specific days/hours):
Do you have any experience with special needs children?
Do you have children of your own? If so, please list ages:
What type of childcare do you have while you work?
Would you work in a household with dogs? with cats?
Languages spoken?
Have you ever been convicted of a misdeamon, felony or criminal act? If yes, please explain.
Describe your health:
Do you smoke? Do you drink? How often?
Do you have any physical restriction or impairment? Explain:
Do you have any medical conditions that will make it difficult to work?
ESSAY QUESTION #1: What do you enjoy doing on your free time? What are some of your hobbies and special interests? Tell us about who you are.
Essay Questions #2: What do you enjoy about this type of work?
How many years experience do you have for the job you are applying?