Name

Email

Phone

Comments on your application

Choose the work area in which you want to register:

Select: Select:NannyHousekeeperChefGardenersDriversElderlycareHandymanHome OrganizerOthers

please upload latest photo: (maximum photo size 12mb)

Name:

Last Name:

Your Name

Your Last Name

City:

State:

Enter city

Enter State

Street Addres:

Enter Street Addres:

Zip Code:

Phone Number:

Enter zip code

Enter phone number:

Date Birth:

Enter Birth Date: Ex. D/M/Y

Enter Email:

Enter Email:

Confirm Email:

Confirm your Email:

Are you legally authorized to work in the United States? Are you legally authorized to work in the United States? U.S. Citizen Naturalized Citizen Permanent Resident Work Authorization No

How did he find out about us? How did he find out about us? Facebook Instagram Google reference from a friend

Emergency Contact:

Ex. Jim Smith, husband:

Whats is your most recent verifiable pay rate?

Especify pay rate:

Tell me about yourself:

Especify:

Briefly describe your childcare experience:

Especify:

Can you swim? Can you swim? Expert swimmer Very good swimmer Okay swimmer I can't swim

Are you willing to cook? Are you willing to cook? Yes No

Do you smoke? Do you smoke? Yes No

Can you work with pets in the home? Can you work with pets in the home? Dogs Cats Other

Especify pets

Do you have any lifting restrictions? Do you have any lifting restrictions? Yes No

List all languages in which you are FLUENT List all languages in which you are FLUENT English Spanish Portuguese French Italian Other

Especify:

What day can you work? What day can you work? Monday - Friday Saturdays Sundays Overnights Evenings Other

Especify:

Can you travel? Can you travel? Yes No

Would you like to travel? Would you like to travel? No Weekends only 1 or 2 weeks maximum Up to 1 month at a time Up to 6 months at a time Up to 1 year or more

What is your method of transportation What is your method of transportation My own vehicle Friends and family Public transportation Other

Especify:

How many hours per week do you want to work

Especify:

Do you agree to work with the parents at home? Do you agree to work with the parents at home? Yes No

Have you used any names other than what is listed on this application? Have you used any names other than what is listed on this application? Yes No

Have you been convicted of a misdemeanor and/or felony in the past 7 years? Have you been convicted of a misdemeanor and/or felony in the past 7 years? Yes No Still pending

Do you have any speeding tickets, accidents, suspensions or DUIs in the last 3 years? (check all that apply) Do you have any speeding tickets, accidents, suspensions or DUIs in the last 3 years? (check all that apply) Speeding ticket/s Accident/s Suspension/s DUI None of the above

PERSONAL REFERENCES:

Include 3 personal references, inclundin full names and currents and telephones numbers

EMPLOYMENT:

Most recent employer

Your Title:

supervisor:

State and city:

Phone number:

START DATE:

D/M/Y

END DATE:

D/M/Y

EMPLOYMENT:

Most recent employer:

Your title:

Supervisor:

State and city

Phone Number

START DATE:

D/M/Y

END DATE:

D/M/Y

EMPLOYMENT

Most recent employer:

Your title:

Supervisor:

State and city:

Phone Number:

START DATE:

D/M/Y

END DATE

D/M/Y