Employment Application

Position: Live-in, weekend Nanny, Upper West Side, NYC

BASIC INFORMATION

Last Name:  First Name:  Street Address:  City:  State:  -:Select a State:- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:  Email Address:  Home Phone:  Work Phone:  Cell Phone:

Which is the best number to contact you on: Home Work Cell Have you ever gone by any other name: Yes No If yes, please list names: How long have you lived at your current address: If less than a year, what is your previous address:   Street Address: City: State: -:Select a State:- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Are you legal to work in the U.S.: Yes No What type of position are you applying for: Live-In Live-Out Either   Full-Time Part-Time Number of years of Domestic experience: Date you are available to start: Will you relocate for a position: Yes No What compensation are you seeking: Are you available to travel with the family: Yes No Are you available to work overtime: Yes No What languages do you speak (please list all):

EMERGENCY CONTACT INFORMATION

Who can we contact in the case of an emergency: Street Address: City: State: -:Select a State:- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: Emergency Contact Phone Number: What is your relationship with this person:

PERSONAL INFORMATION

Are you 18 or older? Yes No Can you provide proof of your age? Yes No What are your hobbies? Are you willing to work in a house with children: Yes No Have you ever been convicted of a felony: *The existence of a criminal record is not an absolute bar of employment. Yes No If yes, please explain: Do you have a valid driver's license: Yes No Do you have a clean driving record: Yes No If no, please explain: Are you willing to take a physical examination prior to employment: Yes No Can you perform the job's essential functions with or without limitations?: With Limitation Without Limitation If "With", please explain: Can you meet the job's attendance requirements?: Yes No If no, please explain: Do you smoke: Yes No   Are you willing to work in a home with animals: Yes No If not, please explain: Are you comfortable working with a family of a different religion than you?: Yes No

EDUCATION HISTORY

High School: Year Graduated: College /University/ Trade Schools , Etc. School: Years Attended: Year Graduated: Major/Degree: Medical Skills and/or Certificates:

TRANSPORTATION INFORMATION

Do you have access to a reliable car: Yes No Have you ever been in a car accident: Yes No

EMPLOYMENT and VOLUNTEER HISTORY

Former Employer and Volunteer Position Name #1: Address: Phone Number: Start Date: End Date: Starting Compensation: Ending Compensation: Job Title: Job Description: Reason for leaving this position:     Former Employer and Volunteer Position Name #2: Address: Phone Number: Start Date: End Date: Starting Compensation: Ending Compensation: Job Title: Job Description: Reason for leaving this position:     Former Employer and Volunteer Position Name #3: Address: Phone Number: Start Date: End Date: Starting Compensation: Ending Compensation: Job Title: Job Description: Reason for leaving this position:

CHARACTER REFERENCES

Name: Address: Phone Number: What is your relationship with this person: How many years have you known this person:     Name: Address: Phone Number: What is your relationship with this person: How many years have you known this person:     Name: Address: Phone Number: What is your relationship with this person: How many years have you known this person:       Please describe how you would like Estate Domestics to describe YOU to your future family: Please explain why you feel you are an excellent candidate for domestic placement:

NANNY/GOVERNESS POSITION SPECIFIC INFORMATION

What made you decide to become a Nanny/Governess? What type of position are you seeking? Your favorite ages of children to care for: Newborns Infants Toddlers (2-6) Pre-Adolescences (7-9) Pre-Teens (10-12) Teens (13-17) Can you care for more than one child at a time: Yes No When did you first start working with children? What do you think is important to the growth and development of a child today? What types of activities will you do with the children? What types of activities will you suggest for rainy days? What is your childcare discipline philosophy? Do you swim: Yes No Are you currently CPR certified: Yes No Have you ever had Pediatric CPR training: Yes No What is your philosophy regarding children and television video games? What type of relationship are you seeking between you and the children in your care? What type of relationship are you seeking between you and your employer?

I agree to the terms and conditions.

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