Position Type:
|
Nanny Housekeeper Caregiver/Companion Chef House Manager Other
|
Looking For:
|
Live-out Live-in Full Time Part Time
|
Desired Salary:
|
$
|
Applicant Information
|
* Last Name:
|
|
* First Name:
|
|
Middle Name:
|
|
Address:
|
Apt.
|
City:
|
|
State:
|
|
Zip Code:
|
|
* Home Phone:
|
|
Cell Phone:
|
|
Fax:
|
|
* Email:
|
|
Social Security #:
|
(xxx-xx-xxxx)
|
Date of Birth:
|
(mm-dd-yyyy)
|
Previous Home Address if less than seven years at the above address:
|
Previous Address:
|
Apt.
|
City:
|
|
State:
|
|
Zip Code:
|
|
|
Do You Drive:
|
Yes No
|
If No, Type of Transportation:
|
|
Driver's License #:
|
|
Expires:
|
(mm-dd-yyyy)
|
Do You Own an Automobile: Yes No
|
If Yes, Make/Model: Year: # of Passengers:
|
Do you have Auto Insurance: Yes No
|
Are you willing to use your car for work purposes: Yes No
|
|
Were you born in the U.S.: Yes No
|
If not, where were you born: Years in U.S.:
|
Are you a U.S. Citizen: Yes No If not, do you have work authorization: Yes No
|
Do you have a U.S. Resident card: Yes No If yes, Card #:
|
Do you have a California ID card: Yes No If yes, Card #: Expires: (mm-dd-yyyy)
|
What is your primary language: What other languages do you speak:
|
|
Do you smoke: Yes No
|
Do you drink: Yes No
|
Are you allergic to pets: Yes No If yes, what kind of pets:
|
Do you know how to swim: Yes No
|
Do you cook: Yes No If yes, at what level Gourmet Basic Children only
|
What Days are you available to work:
|
Mon Tue Wed Thur Fri Sat Sun
|
What Hours are you available to work:
|
From: To:
|
|
Do you have a CPR card: Yes No If yes, Expiration Date: (mm-dd-yyyy)
|
Do you know the emergency phone number to call in the U.S.: Yes No What Is It:
|
Have you ever taken a Tuberculosis (TB) test: Yes No Date Taken: (mm-dd-yyyy)
|
How is your health: Excellent Good Fair Poor
|
Are you physically restricted from working with children, elders or doing housework: Yes No
|
If yes, explain:
|
Marital Status: Married Single Divorced/Separated Widowed
|
Do you have any children: Yes No
|
If yes, ages: (1) (2) (3) (4) (5)
|
Emergency Contact Name: Phone: Relationship:
|
How did you hear about us or who recommended you:
|
|
Education Information
|
High School:
|
Name:
|
Course of Study:
|
|
|
Location:
|
Year of Graduation:
|
|
College:
|
Name:
|
Course of Study:
|
|
|
Location:
|
Year of Graduation:
|
|
Other:
|
Name:
|
Course of Study:
|
|
|
Location:
|
Year of Graduation:
|
|
|
Licensing
|
Do you have any advanced or vocational training in your field: Yes No
|
If yes, explain:
|
Licenses and certificates:
|
Are you registered with Trustline: Yes No
|
Hobbies, interests or organizations you participate in:
|
|
Experience
|
Childcare
|
I am experienced with children of the following ages: (Check all that apply):
|
Newborn to 12 months
|
13 months to 24 months
|
2 to 5 years old
|
5 to 10 years old
|
Older than 10 years
|
Special Needs/ Disabled
Explain:
|
In what capacity of childcare have you had experience:
|
Live-out Nanny
|
Live-in Nanny
|
Preschool Teacher
|
Teacher
|
Camp Counselor
|
Church Nursery
|
Day Care Center
|
Relatives
|
Other
|
Please list activities that you enjoy doing with children:
|
|
Housekeepers
|
I am experienced and willing to help with the following household chores should they become part of my job description?
|
General Housekeeping
|
Light Housekeeping
|
Laundry
|
Meal Preparation
|
Grocery Shopping
|
Ironing
|
|
Eldercare/Companions
|
Can you lift a patient? Yes No
|
Can you bathe a patient? Yes No
|
Can you dress a patient? Yes No
|
Will you run errands? Yes No
|
Can you do the housekeeping? Yes No
|
Can you prepare meals? Yes No
|
Do you have experience with patients that suffered from:
|
Alzheimer’s disease
|
Parkinson’s disease
|
Diabetes
|
Heart Condition
|
Stroke
|
Cancer
|
Other
|
|
Former Employers (List current or most recent references first)
|
Date Employed: From: (mm/dd/yyyy) To: (mm/dd/yyyy)
|
Name:
|
Phone #:
|
Work/Cell #:
|
Address:
|
Job Title:
|
Final Salary $:
|
Number of children or patients you cared for:
|
Ages when you began:
|
Job Duties:
|
Reason for Leaving:
|
|
Date Employed: From: (mm/dd/yyyy) To: (mm/dd/yyyy)
|
Name:
|
Phone #:
|
Work/Cell #:
|
Address:
|
Job Title:
|
Final Salary $:
|
Number of children or patients you cared for:
|
Ages when you began:
|
Job Duties:
|
Reason for Leaving:
|
|
Date Employed: From: (mm/dd/yyyy) To: (mm/dd/yyyy)
|
Name:
|
Phone #:
|
Work/Cell #:
|
Address:
|
Job Title:
|
Final Salary $:
|
Number of children or patients you cared for:
|
Ages when you began:
|
Job Duties:
|
Reason for Leaving:
|
|
Date Employed: From: (mm/dd/yyyy) To: (mm/dd/yyyy)
|
Name:
|
Phone #:
|
Work/Cell #:
|
Address:
|
Job Title:
|
Final Salary $:
|
Number of children or patients you cared for:
|
Ages when you began:
|
Job Duties:
|
Reason for Leaving:
|
|
Date Employed: From: (mm/dd/yyyy) To: (mm/dd/yyyy)
|
Name:
|
Phone #:
|
Work/Cell #:
|
Address:
|
Job Title:
|
Final Salary $:
|
Number of children or patients you cared for:
|
Ages when you began:
|
Job Duties:
|
Reason for Leaving:
|
|
Date Employed: From: (mm/dd/yyyy) To: (mm/dd/yyyy)
|
Name:
|
Phone #:
|
Work/Cell #:
|
Address:
|
Job Title:
|
Final Salary $:
|
Number of children or patients you cared for:
|
Ages when you began:
|
Job Duties:
|
Reason for Leaving:
|