General Information

Full Name
Social Security Number
Position Sought:
 
 Full Year Live In
Summer Live In
Housekeeper Live In
Live-Out Nanny
Date Available
Desired Salary Range


Address Information

Present Street Address
Apt/Suite
City
State
Zip
Present Phone Number
Best Time To Call
E-mail


Permanent Address Information

Permanent Street Address
Apt/Suite
City
State
Zip Code
Permanent Phone Number


Other Information

Do you have a valid driver's license? Yes No
License number and state
Can you drive a standard transmission? Yes No
Will you bring your own car? Yes No
Are you in good health? Yes No
Do you smoke? Yes No
Height
Weight
Can you swim? Yes No
Maximum number of children you will care for:
Minimum age of children you will care for:
Maximum age of children you will care for:
Do you have experience with: Newborns Multiples
Are you willing to work with a mother at home? Yes No
Are you willing to work with pets? Yes No
Do you have any allergies with pets? Yes No
Have you ever been convicted of a crime? Yes No
Number of brothers and sisters?
Marital status: Single Married Divorced
Do you have dependents? Yes No
Ages of your children?
Are you a US citizen? Yes No
Do you have a valid Green Card? Yes No
Where is the Nearest Airport near you?


Education (Please include high school, college(s), and others)

Name and LocationYearsDatesDiploma?
Yes No
Yes No
Yes No
Yes No
Major field of study
Other Interests, Skills, and Talents
Childcare Experience (Nanny, Babysitter, Volunteer, Teacher, Siblings, etc.)

On a scale from 1-10 (with 10 being the highest), please rate yourself:
Neatness
Energy Level
Ability To Adapt To A New Environment
Ability To Communicate Effectively
Organizational Ability
Creativity
Ability To Motivate Others
Are you willing to travel: USA International


Previous Childcare Employment

Employer
Start/End Date (month and year)
Telephone Number
Number Of Children
Ages When Started

Employer
Start/End Date (month and year)
Telephone Number
Number Of Children
Ages When Started

Employer
Start/End Date (month and year)
Telephone Number
Number Of Children
Ages When Started

Employer
Start/End Date (month and year)
Telephone Number
Number Of Children
Ages When Started


Work Experience (Non-childcare related)

Employer
Start/End Date (month and year)
Telephone Number
Responsibilities

Employer
Start/End Date (month and year)
Telephone Number
Responsibilities

Employer
Start/End Date (month and year)
Telephone Number
Responsibilities

Employer
Start/End Date (month and year)
Telephone Number
Responsibilities


Personal References

Name
City, State
Home/Work Telephone Numbers
Relation To You

Name
City, State
Home/Work Telephone Numbers
Relation To You

Name
City, State
Home/Work Telephone Numbers
Relation To You

Name
City, State
Home/Work Telephone Numbers
Relation To You
Why are you interested in becoming a nanny?
What do you think you could offer a family as a nanny?

Upon acceptance of your submitted application, Family Extensions, Inc. will mail a form to you which will require your submission of the following: photograph for identification purposes; copy of birth certificate; High School Diploma; completed questionnaire.

Submission of this application implies that all information stated is true and complete to the best of my ability. I understand that omitting information or providing false information is grounds for immediate dismissal from employment as a nanny. I understand that I am using the services of Family Extensions, Inc. as a referral agency and I will not be considered an employee of Family Extensions, Inc. I understand that I will not be charged a placement fee by Family Extensions, Inc. and the placement fee will be paid by my employer. I agree that I will not travel to Employer's home until required agency fee has been received by Family Extensions, Inc. I understand that if I accept a position with any family referred by Family Extensions, Inc., I will notify Family Extensions, Inc. within 24 hours of acceptance. I understand that Family Extensions, Inc. acts solely as a facilitator and is not responsible, nor liable for any act of the Employer. I also agree to hold Family Extensions, Inc. harmless and to indemnify Family Extensions, Inc. from any and all claims, including attorney fees and court costs made by any person arising out of my employment as a nanny.