Nanny Application General Information Last Name First Name

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					                                 Nanny Application

General Information

Last Name _______________________            First Name ____________________________

Maiden/Other ____________________         Social Security # ___________________________

Date of Birth _______________________

Present Address ________________________________________________________________

City _____________________         State _____________          Zip ___________________

Home Phone ____________________              Cell Phone _____________________________

Have you ever been arrested, or convicted of a misdemeanor or a felony? If yes, please
explain.

______________________________________________________________________________

______________________________________________________________________________

Do you have a valid driver’s license? ______________

Driver’s License number ___________________                 State Issued _______________

Do you have a car? ___________        Make, Model & Year ___________________________

License plate number ___________________________________________________________

Do you have Car Insurance?______________________ Liability?______________________

Do you smoke? _____________________________ Do you like pets?____________________

Do you swim? __________________________________________________________________

Do you have any medical training? ________________________________________________

Are you CPR certified? _________________________________________________________

Are you First Aid certified? _____________________________________________________



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Last Name ____________________________           First Name ___________________________


What are your hobbies and interests? _____________________________________________

If requested, are you willing to complete the process of drug screening, medical testing,

finger printing, psychological testing, or criminal background check? (No cost to you)
____________________________


Background Checks

In order to proceed with background checks please list any previous addresses for the past
seven years.

Address ___________________________            City ____________________

State __________________________               Zip _____________________


Address ___________________________            City ____________________

State __________________________               Zip _____________________


Address ___________________________            City ____________________

State __________________________               Zip _____________________


Education History

High School ______________________             Years Completed ___________

City _____________________________             State __________________________

Phone Number __________________                Graduation Year ________________


College ___________________________            Years attended __________________

City _____________________________             State __________________________

Graduated _______________________              Degree _________________________


College/Other_____________________             Years attended __________

City _____________________________             State __________________________

Graduated _______________________              Degree _________________________

                                                                                             2
Last Name ____________________________            First Name ___________________________


Please list any special training or extra-curricular activities that are related to the childcare
field.

___________________________________________________________________

__________________________________________________________________________


Work History

Please start with your current or most recent job; be sure to list all childcare positions held.

Company Name ______________________             Supervisors Name _______________________

Address ______________________________ Phone # _______________________________

Starting Date __________________________ Ending Date ____________________________

Hours worked /Day _____________________ Salary _________________________________

Ages of Children ________________________ Reason for leaving ______________________

Job Description
_____________________________________________________________________________

_____________________________________________________________________________


Company Name ______________________             Supervisors Name _______________________

Address ______________________________ Phone # _______________________________

Starting Date __________________________ Ending Date ____________________________

Hours worked /Day _____________________ Salary _________________________________

Ages of Children ________________________ Reason for leaving ______________________

Job Description
______________________________________________________________________________

______________________________________________________________________________


Company Name ______________________             Supervisors Name _______________________

Address ______________________________ Phone # _______________________________

Starting Date __________________________ Ending Date ____________________________
                                                                                                3
Last Name _____________________                     First Name _________________


Hours worked /Day _____________________ Salary _________________________________

Ages of Children ________________________ Reason for leaving ______________________

Job Description
______________________________________________________________________________

______________________________________________________________________________


Nanny/Childcare Experience


In what capacity of childcare have you had experience? Please indicate number of years
experience with each:

Live-out Nanny        _____________________________________________

Relatives             _____________________________________________

Preschool Teacher     _____________________________________________

Day Care Center       _____________________________________________

Babysitting           ______________________________________________

Live-in Nanny         _______________________________________________

Camp Counselor        _______________________________________________

Church Nursery        ________________________________________________

Other:                ________________________________________________

What age groups are you willing to work with? Please feel free to check more than one age
group.

         Newborn ______                      Preschooler    ______

         Infant   ______                     School Age    ______

         Toddler ______                      All of the above______

What ages of children do you have experience?______________________________________

______________________________________________________________________________

______________________________________________________________________________

Last Name __________________________                First Name ___________________
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Please list any languages spoken other than English? __________________________

Are you willing to help with the following household chores?

General Housekeeping _______          Grocery Shopping _______         Ironing _______

Running Errands ____________          Cooking __________               Laundry _____

How would you describe your cooking abilities? _____________________________________

______________________________________________________________________________________



Placement Preference


When are you available to start? _________________________________________________

Which position are you applying for? Feel free to check more than one box.

       Live-in _____          Full Time _____        Part Time _____

       Temporary ____         After School ____      Tutor _______

       Mothers Helper _______         Nights & Weekends _________

       Summer Nanny ________

What is your desired salary range? ________________________________________________

What hours are you available?

       Monday_________________________________________

       Tuesday_________________________________________

       Wednesday ______________________________________

       Thursday ________________________________________

       Friday ___________________________________________

       Saturday _________________________________________

       Sunday __________________________________________




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Last Name ______________________ First Name _________________________



Why is a nanny job of interest to you?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Why do you think you would be a good candidate for nanny position?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Please list three personal or professional references (no family members)

__________________        ___________________         _________________     __________
Name                      Address                     Phone                 Years known


__________________        ___________________         _________________     __________
Name                      Address                     Phone                 Years known


__________________        ___________________         _________________     __________
Name                      Address                     Phone                 Years known




E-mail address _________________________________________________________________




_______________________________________                      __________________________
Signature                                                    Date




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