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Nanny_Companion_Applicationp1-102007

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					                   Nanny Companions Application
                         Nanny Companions LLC
                         Linda Brickson
                         3281 Conservancy Estates Ln.
                         Sun Prairie, WI. 53590
                         1-800-960-0464
                         608-837-9307

Today’s date ____________________

First name ___________________________________________________________
Middle name_________________________________________________________
Last name____________________________________________________________
A.K.A & Maiden name _____________________ Need at time of offered employment
Date of birth__________________________________________________________
Social Security Number_____________________ Need at time of offered employment
Driver license #____________________________ Need at time of offered employment
Address______________________________________________________________
_____________________________________________________________________
Phone number(s)______________________________________________________
E-mail address________________________________________________________
Position applying for__________________________________________________
Are you applying for a Full time __________ or Part time? _________________
Date available to start__________________________________________________
Last Physical exam location _________________________Date _______________
Can you make a one-year commitment?___________________________________
Hours and days available to work________________________________________
Do you have a car?_____________________________________________________
 Are you willing to provide a current car insurance policy ____________________
                                           Need at time of offered employment
Maximum number of children you are willing to care for_____________________
I prefer to care for children of the following ages_____________________________

I am experienced with children of the following ages:
     Newborn to 9 months
     9 months to 24 months
     2 to 5 years
     5 to 10 years




                                                                                   1
   Older than 10 years
   Special needs/disabled

Check all of the following that apply:
    CPR certified
    First Aid training
    SIDS (sudden infant death syndrome) educated
    Smoke
    Swim


      Hobbies and Interests:
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________

      Describe your childcare experience With names and phone #’s
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________

      Check all that you are willing to help with, should they become a part of
      your job description.
          General light housekeeping
          Prepare simple meals
          Laundry
          Grocery shopping/running errands
          Ironing
          Pet care


       Do you have any children?________________________________________
       If so, what are their ages?_________________________________________

       How is your overall health? ______________________________________
       _______________________________________________________________
       Do you have any physical limitations that would limit your ability to
       work as a Nanny? ______________________________________________



                                                                              2
Please list the jobs that you have had in the last 5 years, with
Names and Dates, Phone #’s:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________


Please use the following space to give the names and complete addresses
of at least three families you have provided childcare for. Please include
dates of employment, number of children you cared for and general
responsibilities of the position. Please Give Phone #’s
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Highest level of Education
     High school diploma ___________Year of graduation __________
        Name of School
     Some college Name of College
     College 2 year degree in____________________________________
         Name of College __________________________________________
     College 4 year degree in____________________________________
        Name of College ___________________________________________
     Subjects of special _________________________________________
     Associate Degree__________ Name of school__________________




                                                                        3
Do you hold a valid driver license? ________________________________

Please describe your
personality______________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

What are your goals for the
future?__________________________________________________________
________________________________________________________________
________________________________________________________________

What is the worst thing a child could do to upset
you?____________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Please describe your favorite childcare
experience_______________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Why do you desire to be a Nanny?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________




                                                                   4
                                       Need at time of offered employment by a Fa mily
        I authorize Nanny Companions, LLC and/or Fidelitec, LLC, to investigate all statements contained in my
application for employment and retrieve information relating to my past activities for purposes of such
investigation from all relevant individuals and organizations, including but not limited to personnel, educational
institutions, govern ment agencies, companies, law enforcement agencies, and consumer reporting agencies, to
supply any and all information concerning my background and credit worthiness, and release the same from any
liability resulting in providing such information. The information received may include, but is not limited to,
employment, academic, residential, motor vehicle, consumer credit, and criminal records. I understand that I have
the righ t to request additional information a bout these in quiries and any subsequent reference reports. This
additional information will be provided to me upon written request to Fidelitec, LLC, 245 Horizon Drive, Suite 107,
Verona, WI 53593.

                  I hereby certify that all th e statemen ts and answers contained in my application for
                  employment and on this form are true and complete to th e best of my knowledge, and
                  I understand that any false statements and/or answers or omissions of information
                  contained in my application for employment and on this form will be sufficient cause
                  for cancellation of employment consideration or dismissal, if I have been employed. I
                  understand that by furnishing my birth date below, Nanny Companions, LLC and/or
                  Fidelitec, LLC, are using that information for the sole purp ose of verifying
                  identification as part of the criminal records check and the birth date is not part of my
                  application for employment. I release all parties for all liability for any damage that
                  may result from furnishing information, including this disclosure of my date of birth
                  and this authorization to Nanny Companions, LLC and/or Fidelitec, LLC.

                  I authorize that a photocopy or fax of this authorization be accepted with the same authority as
                  the original; and that this authorization be in effect throughout my candidacy for employment
                  and, if employed by Nanny Companions, LLC , this authorization remain i n effect throughout
                  my employment.


                  __________________________________________
                  Print Name (First, Middle Initial, Last)


                  __________________________________________ ______________________
                  Signature                                                        Date




                  _______________________________________________________________________
                  Street                       City                         State         Zip


                  SOCIAL SECURITY NUMBER                                      BIRTH DATE
                            __       __                                       (MONTH/DAY/YEAR)
                  DRIVER'S LICENSE NO.                                        STATE
                                                                                    /
                                                                              EXPIRES           /




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