ONLINE JOB APPLICATION

Personal Information
First Name     Last Name 
Street Address   
City            State              Zip Code    
Home Phone        Cell Phone  
Email Address   Country of Origin 
Date of Birth    Social Security Number 
Do you have a driver's license?    yes    no    If yes, since when?   
State and license number   

Have you ever had a moving violation or traffic accident in the past 3 years?   yes  no
 If yes, please provide specifics.   
Have you ever been arrested or convicted of a felony and/or misdeamenor?  yes  no
Position applying for (check all that apply):   nanny    baby nurse   housekeeper     
companion      live-in       live-out      full-time      part-time

Check all that apply: 
American citizen    Green Card holder    Legally eligible to work in the US
Have Own Vehicle    Swim    First Aid Certified    CPR Certified    Smoke   

Educational Background

What is the highest level of education that you have completed?
List name and location of high school and college (if applicable) attended.

Degree or certificate received?
List any special training that you have had that is relevant to the position(s) you are seeking.


Interests and Preferences
Are you willing to do general housekeeping should it become a part of your job responsibilities?
Are you willing to work around animals? yes  no
Are you willing to provide pet care if it becomes part of your job responsibilities? yes no
What do you enjoy doing on your free time?

Health Information
Have you been immunized against common childhood illnesses?  yes  no 
If yes, please list.
Please indicate if you are willing to submit to each of the following: 
physical exam  yes no    drug screening  yes no    TB test  yes no     HIV test  yes no
Are you currently on medication?  yes no  If yes, please list.
Do you have any medical condition that may affect your ability to perform all your job-related duties?  yes   no   If yes, please explain.

Employment History
Provide the following information on all childcare jobs that you have had for the past 5 years.

1. Current or Most Recent Job
Employer Name    Employed from  to .
Mailing Address   City    State   
Telephone   Position   
Number of children in your care     Ages of children
Describe your responsibilities in detail. 
Reason for leaving   
May we contact this employer? yes no

2.
Employer Name   Employed from   to .
Mailing Address   City  State
Telephone   Position
Number of children in your care     Ages of children
Describe your responsibilities in detail.
Reason for leaving 
May we contact this employer?  yes no 

3.
Employer Name   Employed from  to .
Mailing Address   City   State
Telephone   Position
Number of children in your care   Ages of children
Describe your responsibilities in detail.
Reason for Leaving  
May we contact this employer? yes no

4.
Employer Name    Employed from  to .
Mailing Address  City   State
Telephone   Position
Number of children in your care   Ages of children
Describe your responsibilities in detail.
Reason for Leaving
May we contact this employer? yes no

Personal, Character, or Professional References
       Do not include family members
1.  Name      Relationship  
Length of time known      Phone Number
2. Name    Relationship
Length of time known     Phone Number

Before you submit, please check to make sure that you have completed the form in its entirety.    A representative will review your application and contact you shortly.