Last Name:

First Name:

Middle Initial:

Daytime phone number:		Cell phone number:
FAX number:		E-mail address:

Have you applied with us before, if so when?

What languages do you speak:

Do you have other names you have used in the past 7 years?:

Are you authorized to work in the United States? Yes No

How long have you lived in Las Vegas?

How did you hear about Nannies & Housekeepers U.S.A.?
Were you referred by someone?

Position Desired
Choose all selections that apply

Nanny	House Keeper	Elderly Care	Cook/Chef	Nanny & Housekeeper	Personal Assistant	House/Estate Manager

Full-time		Part-time		Live-in		Live-out		Temporary
Yes No		Yes No		Yes No		Yes No		Yes No

Salary desired:

:

Tell Us About Yourself

Please mark the following questions YES or NO. PLEASE DO NOT LEAVE ANY QUESTIONS UNANSWERED.	YES	NO
Are you willing to work for a smoker ?
Are you at least 18 years of age ?
Do you know how to swim?
Do you have any allergies ?
Are you flexible to change in your schedule ?
Are you willing to drive on the freeway?
Do you have a valid drivers license?
Are you willing to travel?
Do you have your own car?
Do you have car insurance?
Are you willing to work around animals?
Are you willing to commit to a one-year contract?
Do you have any medical problems that prevent you from lifting?

Do you have any physical limitations that would prevent you
from completing the essential functions of the job in which
you are applying?:

Days And Hours You Are Available To Work:

Day of the Week	Start Time	End Time
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Occasional Evenings
Holidays
Nights

Education

	Name of School	City/State/Country	Field of Study	Graduated?	Diploma Received
College
College
Other

 

Describe any child related courses or specialized training or skills that help qualify you for the position you are seeking.

List any computer skills, i.e. MS Word, Excel, Outlook, etc.,

	YES	NO
Are you currently certified in infant and child CPR?
Are you currently certified in First Aid?
If not certified, do you agree to certify prior to or upon referral?

Childcare Experience
Starting with the most recent, list the names of the families that you have nannied for or any other childcare experience, i.e. daycares, church nurseries, day camps, teaching, etc. DO NOT LIST RELATIVES.

Name of Family or Facility:	Your Job Title:	Number of Children and Ages:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:
Days and Hours Worked Per Week:

Name of Family or Facility:	Your Job Title:	Number of Children and Ages:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:
Days and Hours Worked Per Week:

Name of Family or Facility:	Your Job Title:	Number of Children and Ages:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:
Days and Hours Worked Per Week:

Name of Family or Facility:	Your Job Title:	Number of Children and Ages:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:
Days and Hours Worked Per Week:

Name of Family or Facility:	Your Job Title:	Number of Children and Ages:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:
Days and Hours Worked Per Week:

Check ALL age groups that you have experience with:

Newborns (4 months or younger)	Infants	Ages 1-2	Ages 3-6	Ages 7-13

Have you worked with children with special needs?

Describe your methods of behavior management and discipline:

Work Experience
Starting with the most recent employer, list full-time, part-time, and volunteer work for the last 10 years related to the position applied for. Account for any gaps in employment. Do not list child-related experience in this section.

Name of Employer:	Your Job Title:	Supervisor:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:

Name of Employer:	Your Job Title:	Supervisor:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:

Name of Employer:	Your Job Title:	Supervisor:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:

Name of Employer:	Your Job Title:	Supervisor:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:

Name of Employer:	Your Job Title:	Supervisor:
Dates Employed:		Phone Number:
Reason for Leaving:
Duties Performed:

During the past ten years, were you ever fired from any job for any reason? Please explain.

Have you ever been convicted of a misdemeanor, felony or criminal act? If yes, give dates, locations,
and disposition.

Personal References
List (3) three personal references you have known for at least (5) five years. Do not include relatives.

Name:	Years Known:	Phone:	Relationship:

 AUTHORIZATION AND CONSENT FOR THE RELEASE OF INFORMATION

This authorization and consent for release of personal information acknowledges that Nannies and Housekeepers U.S.A. (hereinafter referred to as “company” and or its agent) may conduct investigations. These investigations might include but are not limited to searches or financial or credit agencies, records of previous employment including detailed information on files in local, state, or federal agencies, worker compensation records, and motor vehicle/drivers license records.

I understand that these searches will be used to determine employment eligibility under the company’s employment policies. Therefore, I authorize and consent to full release of records (either orally or in writing) to the authorized representative of the company. In addition, I release and discharge the company and its agents and associates to the full extent permitted by law from any claim, damages, losses, liabilities, costs, expenses, or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that this notice will apply to any future update reports that may be requested and is valid for up to one year from the below date for hiring purposes. After reading this document, I understand fully its complete content and I authorize the background verification.

I hereby attest that all of the above and previous pages of this application are true. Also, by signing this application I promise to allow Nannies and Housekeepers U.S.A. to act as my exclusive employment agency on all the interviews that I am sent to. I will not contact or directly accept employment from any family that I am introduced to by Nannies and Housekeepers U.S.A. I give permission for Nannies and Housekeepers U.S.A. to contact my references and also do a background check before I start work. I hereby give Nannies and Housekeepers U.S.A. permission to share my information with potential families that may be interested in retaining me for employment.

By submitting, e-mailing, delivering this application to Nannies & Housekeepers U.S.A. you are agreeing to all terms outlined in the application