ONLINE APPLICATION UNDER CONSTRUCTION

NOT READY TO USE! PLEASE DOWNLOAD APPLICATION AND FAX.

Sample Nanny Application

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Major Cross Streets:
Email Address:
if needed, create one at www.hotmail.com
Home Phone Number:
Mobile Number:
How Long at Address?

If less than 5 years at above address, enter previous address info below

Previous Address:
City:
State:
Zip Code:

Create User Name and Password (Name and Password will automatically be e-mailed to above address)

Create User Name :
Create Password :
Confirm Password :

Nanny Application

Social Security Number
Country of Birth:
Date of Birth:
Are you a U.S. Citizen?
If Not, explain your USA work status:
Parents Name(s):
Parents Phone Number:
Emergency Contact Name:
Local Name Preferred
Emergency Contacts Phone #:

Desired Job Information

Living Arrangements:
Can You Commit a Year::
Date Ready to Work:
Weekly Hours Desired:

List Available Times You Are Willing to Work During the Week

MON:
 Morning Afternoon Evenings
TUE:
Morning Afternoon Evenings
WED:
Morning Afternoon Evenings
THU:
Morning Afternoon Evenings
FRI:
Morning Afternoon Evenings
SAT:
Morning Afternoon Evenings
SUN:
Morning Afternoon Evenings
Can you work Overnight or Weekends once in a while:
If Yes, Explain :
Do you have any future vacation plans schedule:
If Yes, Explain :
Want to be called for Temp Babysitting/Nanny jobs:
If Yes, Explain :

Nanny Application

Childcare References (List Most Recent First)

Family Name:
State:
Evening Phone Number :
Last Date with Children:
Daytime Phone Number :
Total Time with Children :
Children's Ages:
Duties:

Family Name:
State:
Evening Phone Number :
Last Date with Children:
Daytime Phone Number :
Total Time with Children :
Children's Ages:
Duties:

Family Name:
State:
Evening Phone Number :
Last Date with Children:
Daytime Phone Number :
Total Time with Children :
Children's Ages:
Duties:

Family Name:
State:
Evening Phone Number :
Last Date with Children:
Daytime Phone Number :
Total Time with Children :
Children's Ages:
Duties:

 

Have you left out references you though would be Bad:
If Yes, Explain :

Nanny Application

Personal References (Do Not Use Relatives)

Personal Reference Name:
State:
Evening Phone Number :
Years Known:
Daytime Phone Number :
Relationship:

Personal Reference Name:
State:
Evening Phone Number :
Years Known:
Daytime Phone Number :
Relationship:

 

Personal Reference Name:
State:
Evening Phone Number :
Years Known:
Daytime Phone Number :
Relationship:

 

Any chance of your references giving you a poor report:
If Yes, Explain :

Nanny Application

Work History (Most Recent First)

Employer/Business:
State:
Manager's Name :
Start Date :
Phone Number :
End Date :
Your Position Held :
Ending Salary :
Job Duties/Description:
Reason for Leaving :

Employer/Business:
State:
Manager's Name :
Start Date :
Phone Number :
End Date :
Your Position Held :
Ending Salary :
Job Duties/Description:
Reason for Leaving :

 

Employer/Business:
State:
Manager's Name :
Start Date :
Phone Number :
End Date :
Your Position Held :
Ending Salary :
Job Duties/Description:
Reason for Leaving :

 

Have you even been fired from a position:
If Yes, Explain :

Nanny Application

Education

Education Level :
State:
School's Name :
Years Attended :
Still Enrolled :
Graduated Yet :
Subjects Studied:

 

Education Level :
State:
School's Name :
Years Attended :
Still Enrolled :
Graduated Yet :
Subjects Studied:

 

Education Level :
State:
School's Name :
Years Attended :
Still Enrolled :
Graduated Yet :
Subjects Studied:

 

Education Goals :

Nanny Application

Driving Information

Do you have a Vehicle:
Is your License Active:
Vehicle Make and Model:
Driver's License Number:
# of Seatbelts in Vehicle:
License Expiration Date:
Comfortable Driving Children:
State License Issued:
Ever Lose Your License:
Auto Insurance Company:
Describe Driving Record:
Insurance Phone Number:
Tags / Registration Current:
Insurance Expiration Date:
Describe Tickets/Accidents:

Criminal Record

Have you ever been Convicted or Accused of a Crime :
If Yes, Explain :
Have you ever received a DUI or DWI:
If Yes, Explain :
Living with or Seeing Someone Convicted of a Crime:
If Yes, Explain :
Have you or anyone associated with you been Accused or Convicted of Child or Sexual Abuse:
If Yes, Explain :
States Lived in during past 5-Years :
Countries Lived During past 5-Years :

Nanny Application

Health Questions

Do you have Health Insurance:
When was your last Physical:
Are you currently in Good Health:
If No, Explain :
Are you currently under Physicians Care:
If Yes, Explain :
Are you currently taking Medications:
If Yes, Explain :
Do you have any Illnesses (Tuberculoses, HIV...):
If Yes, Explain :
Do you suffer from Mental or Emotional Illness:
If Yes, Explain :
Have you ever been treated for Alcoholism:
If Yes, Explain :
Have you ever experimented with Illegal Drugs:
If Yes, Explain :
Do you suffer from any Substance Abuse :
If Yes, Explain :
Are you hampered by Back Disorder:
If Yes, Explain :
Ever file for Workman's Compensation:
If Yes, Explain :
Do you Smoke:
If Yes, Amount:
Do you consume Alcohol:
If Yes, Amount:
Allergies (Pets, Foods, Plants...):
If Yes, List :

Please list any past health illnesses or concerns you may have...

Other Health Concerns :

Nanny Application

Certifications / Training / and Abilities

Certified in CRP/First Aid:
If No, will you become certified:
If Yes, State Expiration Date:
Can you Swim:
Do you feel comfortable Watching with Children around a Pool:
Any other Training or Certifications:
If Yes, Describe:

CNA, Lifeguard, Child Development

Miscellaneous Questions to help us match personalities

Do you play sports and are willing to participate:
If Yes, Describe:
Do you play any Musical Instruments:
If Yes, Describe:
Do you like Arts and Crafts:
If Yes, Describe:
Do you believe in Disciplining Children :
Please Explain:
Are you Married or currently in a Relationship:
Please Explain:
Do you have Children or are you Pregnant:
If Yes, Describe:
List Children(s) ages and explain who cares for them daily, and when sick:
Will an Employers Religion matter to you :
What's your Religion:
Do you have any Computer Skills:
If Yes, Describe:
Do you Dislike Pets:
If Yes, Explain:

Understanding Children are the First Priority, select task you are willing and able to do...

Car Pooling:
 Yes No
Grocery Shopping:
Yes No
Kids Laundry:
Yes No
Adult Laundry:
 Yes No
Light Housekeeping:
Yes No
Tutoring:
Yes No
Running Errands:
 Yes No
Cooking for Kids:
Yes No
Cooking for Adults:
Yes No
Upkeep Kids Mess :
 Yes No
Light Dishes:
Yes No
Feeding Pets:
Yes No

Nanny Application

Personality Profile

Describe in detail the type of person you are:
What would you say are your Best Personality Traits :
What's your most Significant Personality Weakness:

Please Rank yourself from 1-10 on the following (10 being the best)

Responsibility:
Love for Children:
Honesty:
Moral Values:
Organization:
Communication Skills:
Common Sense:
Ability to be On Time:
Dependability:
Patience:
Attention to Details:
Learning Ability:
Positive Attitude :

Select the circle that show how much you agree with the following (1-Strongly Agree to 5-Strongly Disagree)

I am a Private Person
My surroundings must be clean
I have many Interest
I enjoy Playing with Children
I am a Good Cook
I'll Compromise to Resolve Disputes
I Love to Laugh
Creative / Enjoy Planning Activities
I am a Perfectionist
I am a Good Listener
I enjoy Reading
I Follow Directions Well
I am a Self Starter
I Stay Calm in Stressful Situations

Nanny Application

Last Page, You Made It!

How did you hear about The Nanny Exchange:
If other Explain:

For a free gift, list the name of friends or family members you think would be interested in a position

 

First Referral

Second Referral

Third Referral

Persons Name:

Relationship:

Phone Number:

Consent

YES, I UNDERSTAND THE NANNY EXCHANGE WILL NOT BE CHARGING ME A FEE FOR FINDING EMPLOYMENT. THE FEE FOR MY PLACEMENT WILL BE CHARGED TO THE FAMILY I AM HIRED BY. IN THE EVENT THE FAMILY FAILS TO PAY THE REQUIRED FEE, I UNDERSTAND I SHALL BECOME LIABLE FOR THE FEE IF I CONTINUE TO WORK FOR THE FAMILY.

I HEREBY ACKNOWLEDGE THAT THE FOLLOWING FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE, AND UNDERSTAND THAT IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE A FULL BACKGROUND INVESTIGATION ON ALL STATEMENTS CONTAINED HEREIN. I ALSO AUTHORIZE MY PERSONAL REFERENCES AND EMPLOYERS TO RELEASE TO THE NANNY EXCHANGE INC. ANY AND ALL-PERTINENT INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT. THE NANNY EXCHANGE, INC. HAS MY PERMISSION TO RELEASE ALL INFORMATION THEY COMPILE TO MY PERSPECTIVE EMPLOYER. THE NANNY EXCHANGE, INC. IS A REFERRAL SERVICE AND IS NOT MY EMPLOYER. IT IS UP TO ME AND THE EMPLOYER TO NEGOTIATE ALL TERMS AND CONDITIONS OF EMPLOYMENT, INCLUDING COMPENSATION. THE NANNY EXCHANGE, INC. IS NOT RESPONSIBLE FOR COMPLETING ANY BACKGROUND INVESTIGATIONS OF THE PERSPECTIVE EMPLOYER. THE NANNY EXCHANGE, INC. AND ITS' OWNERS, DIRECTORS, OFFICERS, EMPLOYERS, AND AGENTS ARE NOT LIABLE FOR LOSSES, DAMAGES, COSTS, DEMANDS, SUITS, JUDGMENTS, CLAIMS, OR EXPENSES, RELATED TO THE REFERRAL. I AGREE TO HOLD THE NANNY EXCHANGE, INC. HARMLESS FROM ANY AND ALL DAMAGES OR CLAIMS RESULTING FROM ANY FALSE OR MISLEADING INFORMATION PROVIDED ON THIS APPLICATION. I HAVE NOT OMITTED ANY MATERIAL FACTS OR INFORMATION WHICH MAY AFFECT MY SUITABILITY FOR EMPLOYMENT. I AGREE TO SUBMIT TO A FULL DRUG AND ALCOHOL SCREENING AS MAY BE REQUESTED BY ANY EMPLOYER OR PROSPECTIVE EMPLOYER.

Type Your (Applicant) Signature Date