Help Domestic/Nanny Agency

The fields marked with (*) are required fields. * Last Name:  * required * First Name:  * required * Middle Name:  * required * Present Address, City, State: * Zip Code:  * required * Birth Date:  * required * Age:  * required * Place of Birth:  * required * Marital Status: Single Married Divorced Widowed * Sex: Male Female * Height & Weight: * Home Tel:  * required   Alternate Phone No:   Cellular Phone No: * Social Security No:  * required * TDL # OR ID #:  * required * Are you a U.S. citizen? Yes No * If no, please provide employment status: Permanent Resident Card Resident Alien Card Employment Auth. Card Temporary Status of Employment Card Other N/A   Alien Resident No:A- * Education: G.E.D High School College Other * Percent of English Spoken: 0% 10% 20% 40% 60% 80% 100% Bi-lingual * Do you own a car? Yes No * Please check the type of nanny position you are applying for: Full-Time, Live-In Full-Time, Live-Out Part-Time, Live-in Part-Time, Live-out Ft/Pt, Weekends Night Shifts, Weekends Night Shifts, Weeknights On call Shifts Other * Days Available for Employment: Monday Tuesday Wednesday Thursday Friday Saturday Sunday * Are you willing to work weekends? Yes No * Are you willing to:(for the children) Cook Iron Clean Do Laundry none of the above * Are you willing to:(for the whole family)? Cook Iron Clean Do Laundry None of the above * C.P.R. Certified? Yes No * Are you willing to relocate out of state? Yes No   Do you smoke? Yes No * Are you allergic to pets? Cats Dogs Other * Please describe your physical condition? Excellent Good Fair * Present Employer (family name):  * required * Position Held ? Ages of children? How Many? * Phone #, Work #, Cell #,: * Employment Dates From:MM/DD/YY  * required * To:MM/DD/YY  * required * Reason For Leaving? * Family Name:  * required * Position Held? Ages of Children? How many? * Phone #, Work #, Cell #: * Employment Dates: From: MM/DD/YY: * To:MM/DD/YY:  * required * Reason For Leaving? * Family Name:  * required * Position Held? Ages of Children? How Many? * Phone #, Work #, Cell # :  * required * Employment Dates: From:MM/DD/YY: * To:MM/DD/YY:  * required * Reason For Leaving?
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