Nanny Application Form
Personal Contact Information
Name (first & last)				Maiden Name
Date				Date Available to Start
Home Address				City
State			AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY	Zip Code
Nearest Town or Major Crossroads
Home Phone				Cell Phone / Pager
Are You Eligible to Work in U.S.			Yes   No
Your E-mail
Type of position you are seeking (check as many as apply)
Permanent	Full-time	Days	Weekends
Temporary	Part-time	Evenings	24 hour / Overnight
College Breaks	Live-in	Work around your school schedule
Days / Hours Available
Do you have an insured, reliable vehicle to transport children of any age?			Yes   No
Do you have children that you want to bring with you to your nanny position?			Yes   No
Please describe (male/female, age, etc.)
Other Information
Will you work w/ mothers at home?			Yes  No
A valid driver's license?			Yes   No
Are you in good health?			Yes   No
Do you smoke?			Yes  No
Can you swim?			Yes   No
Work w/ pets?			Yes  No
Allergies to pets?			Yes  No
Convicted of a crime?			Yes  No
Number of siblings?			Yes   No
Are you a US citizen?			Yes   No
Valid green card?			Yes  No
Willing to travel?			Yes   No
What language are you most fluent in?
What other languages are you fluent in?
Education
High School Name
City/State
Years attended
Did you graduate?			Yes   No
Year
College Name
City/State
Years attended
Did you graduate			Yes   No
Year
Major
College / Trade School Name
City/State
Years attended
Did you graduate			Yes   No
Year
Have you had CPR?			Yes   No	Expiration Date
Have you had First Aid?			Yes   No	Expiration Date
Have you taken any Education classes?			Yes   No
Have you taken Child Development courses?			Yes   No
Child Care Experience
Employer One
Start Date
Leave Date
Employer Name
City
State			AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
Phone
Chidren: Gender and Ages(age when first started with family):
Position/Duties
Reason For Leaving
Pay Rate
Employer Two
Start Date
Leave Date
Employer Name
City
State			AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Phone
Chidren: Gender and Ages(age when first started with family):
Position/Duties
Reason For Leaving
Pay Rate
Employer Three
Start Date
Leave Date
Employer Name
City
State			AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Phone
Chidren: Gender and Ages(age when first started with family):
Position/Duties
Reason For Leaving
Pay Rate
How Did You Hear Of Us?
Please tell us how you heard about us			Choose an Option NewspaperReferralPhone BookInternet
Other
I certify that all of the information included in this application is accurate to the best of my knowledge. I understand that knowingly withholding information or providing false information is grounds for immediate dismissal from employment.