Fields marked with a white asterisk* are required to submit this form.

*First Name:

*Last Name:

*Current Address:

*City:

*State:

*Zip Code:

*How Long at this Address?

Please list addresses for previous five years:
*Address 1:

Address 2:

Address 3:

Address 4:

Address 5:

Work Phone:

*Home Phone:

Cell Phone:

Fax:

*Email:

Social Security #:

Geographic Areas Preferred:
*Preference #1:

*Preference #2:

*Available Starting Date:

*Requested Salary:

*Position Desired
(must check at least one):

Nanny - Live in

Nanny - Live out

After School Care

Summer

Part Time

Full Time

*Are you interested in and able to take a permanent position? Yes No

(At least one year?) Yes No

*Ages of children you have previously cared for:

*Ages of children you would like to care for:

*How many children have you cared for at any one time?

*Would you work in a single-parent home? Yes No

*Would you work in a home with pets? Yes No Other

Please explain:

*Would you work in a home where someone smokes? Yes No

*Do you smoke? Yes No
If yes, how much per week?

*Do you drink? Yes No
If yes, how much per week?

*Will you work in a home where
(check all that apply):

Both parents work

Father stays home

Mother stays home

Both parents stay home

*Are you willing to do housework for additional money? Yes No

*How do you rate yourself as a cook? Good Fair Poor

*Will you prepare meals for the entire family? Yes No

*How did you hear about our company?

*Current Employment

*Current Employment Address:

*May we contact your current employer? Yes No

Please provide your employer's contact information :

Do you live with your parents? Yes No

Parent's address (if living with them):

Number of brothers:

Number of sisters:

What is your birth order? Example: Brother Joe, Sister Sue, Myself, Brother John

*Have you ever had children Yes No

If yes, are you looking for a position where you can take your children with you? Yes No

*Do you have any involvement with youth organizations? Yes No

If yes, explain:

*Do you have any experience with handicapped or special needs children? Yes No

If yes, explain:

*Are you certified in CPR? Yes No

*Are you certified in First Aid? Yes No

*Can you swim? Yes No

*Are you certified in lifesaving? Yes No

*Will you have a car? Yes No

Year/Make:

*Driver's License Number:

*State of License:

*Can you operate a stick shift? Yes No

*Has your driver's license ever been suspended? Yes No

If yes, please explain in full.

*Have you ever had any traffic accidents or traffic tickets? Yes No

If yes, please explain in full.

*Have you ever been arrested? Yes No

If yes, please explain in full.

*Have you ever been convicted of a crime? Yes No

If yes, please explain in full.

Will you consent to the following if requested by the company or a family :

*Background Check? Yes No

*Drug screening? Yes No

*Physical examination? Yes No

*HIV screening? Yes No

What are some of your hobbies or interests?

*Weekly Hours available
(one checkmark per day except for Saturday and Sunday is required)

*Monday: 6-9am 9am -5pm 5-7pm 7-10pm

*Tuesday: 6-9am 9am -5pm 5-7pm 7-10pm

*Wednesday: 6-9am 9am -5pm 5-7pm 7-10pm

*Thursday: 6-9am 9am -5pm 5-7pm 7-10pm

*Friday: 6-9am 9am -5pm 5-7pm 7-10pm

Saturday: 6-9am 9am -5pm 5-7pm 7-10pm 10pm-2am

Sunday: 6-9am 9am -5pm 5-7pm 7-10pm 10pm-2am

Please explain in detail why you are looking
for a nanny position:

"By Submitting this application, I certify that all of the information included in this application is accurate to the best of my knowledge. I understand that knowingly withholding information or providing false information is grounds for immediate dismissal from employment."