This is a generick nanny application containg the information you need to preform a good background check on the applicant.  Any area in yellow you need to put your informatin in before printing.

Today’s Date: _______________________________
Last Name: ___________________ First: ________________
Social Security Number: _______ Driver’s License # _______
Address: __________________________City: ____________ State: ______ Zip: _____
Home phone: _______________________ Cell Phone: _________________
Email address: __________________________Date of Birth: _____________________
Education/ Experience:
High School: ___________________ Years Attended: _______Did you graduate? _____
College: _______________________ Years Attended: _______Did you graduate? _____
Post Graduate: ___________________ Years Attended: _______Did you graduate? ____
Subjects Studied in College: _____________________________________________
Are you certified in: CPR? Yes______ No______ Certification Date________________
First Aid? Yes_____ No_____ Certification Date________________
Do you know how to swim? Yes_________ No________________
Please list any additional childcare classes: _____________________________________
Play musical instruments? _______ What kind? _________________________________
Other Languages (if any): __________________________________________________
Would you do pet sitting?___Yes___No Would you do adult care sitting?___Yes___No
Date you can start: __________
Days and time you would be required to work: ____________Monday _________Tuesday ________Wednesday
___________Thursday ___________Friday ___________ Saturday___________ Sunday
Do you have a conflict with any of these days and times____________________________

Place Photograph Here
*For Identification
Purposes*
Page 2

Are you a U.S. Citizen? _______________________________________________
These are the duties you would be expected to fullfil (Check all that apply)
_ Drive children _ Complete housekeeping _ Laundry for children
_ Cooking for family _ Run errands _ Light housekeeping _ Laundry for family
_ Cooking for children _ Grocery shop _ Iron clothes _ Overnight care
Do you have a conflict with any of these duties____________________
Weekly Salary Range: ________________________ Gross or _ Net of taxes
Health Insurance: Need it? _ yes _ no _ negotiable Do you currently have it? _ yes _
no Cost $________/month
These are the ages of our children (Check all that apply)
_____ Newborn _____1-5 years old
_____3-6 months _____5-10 years old
_____6-12 months _____10 and older
Do you feel uncomforyable with any of these ages?______________________
Do you have reliable transportation? Yes ______ No ______
What form of transportation will you be using? _________________________
Do you smoke? Yes ___No ___Will you agree not to smoke on the job? Yes ___ No ___
Do you like animals? ___ Would you be willing to work in a home with indoor pets? ___
We have the following Pets_____________________________________
Child Care Experience: ____________________________________________________
Personal Experience:
Do you have children? Yes_________ No_________
If yes, what ages are your children now? ________________________
Do your children require childcare? Yes_________ No_________
If yes, will you need to bring them with you while sitting? Yes ______ No______
Will you prepare simple meals? Yes_________ No_________
Are you willing to supervise play time with other children while on the job?
Yes_____No_____
Are you willing to drive children to gymnastics/ soccer/ or other group activities?
Yes_________ No_________
Are you comfortable reviewing and assisting with homework? Yes______ No______
Do you have any known medical problems or Allergies? Yes _________No __________
If yes, please explain: _____________________________________________________

Page 3
Work Experience:
1. Employer _________________Position Held: __________From: ______To ______
Contact person: ___________________Phone Number: ___________________
Description: _____________________________________________________________
________________________________________________________________________
2. Employer ______________Position Held: ______________From: ______To ______
Contact person: ___________________Phone Number: _______________________
Description: __________________________________________________________
_______________________________________________________________________
3. Employer _______________Position Held: ____________From: ______To ______
Contact person: _________________Phone Number: ________________________
Description: _________________________________________________________
_______________________________________________________________________
List of Character References: (Preferably Child Care)
1. Name __________________________Phone Number __________________________
2. Name __________________________Phone Number __________________________
3. Name __________________________Phone Number __________________________
Background Information (required)
Will you:
I Authorize a Criminal Records Check? Yes _____________No _______________Please Initial_______
I Authorize a Sex Offender Registry Check? Yes __________No _____________Please Initial_______
I Authorize a Driver of Motor Vehicle Check? Yes __________ No __________Please Initial_______
We ask Nannies for permanent positions to accept assignment for one year. Are you willing to make this commitment? _Yes _ No
I understand the information on this application has been requested for the purpose of evaluating my qualifications for employment. To the best of my knowledge, the information in this application is true.

I understand that misrepresentation or omission of facts in connection with my application may be sufficient cause, in and of itself, for dismissal whenever discovered.

I allow the release of this information for purposes of employment.

________________________________________ ________________________
Print Full Name Date
_________________________________________ ______________________
Signature Date

Page 4
BACKGROUND REFERENCE AUTHORIZATION
In order to determine whether a candidate is suitable for a position, it is necessary to thoroughly review your complete employment history, driver’s record, and references.
Many employers and references will not provide a candid response unless there is an authorization and release of liability statement. Please carefully review the following paragraph and sign and date the form below.
I, _______________________________________________________, hereby authorize the Employer name and ID# and any agent acting on its behalf to contact my former employers and references and conduct a complete background review, including criminal, motor vehicle, and sex offender’s record.

I authorize release and forever discharge eachemployer, reference, police and motor vehicle department, sex offender registry, educational institution, the Emplyer Name and ID# and its employees and agents from any and all liability of any kind or nature whatsoever relating to my complete background, driver’s record, and reference review. I further specifically request that all agencies, representatives, and references fully cooperate with this investigation.

If employed, I further authorize periodic checks of all above referenced sources as may be deemed necessary by employer.
______________________________________ _______________________________________
Print Full Name Signature
______________________________________ ________________________________________
Social Security Number Date
______________________________________ _________________________________________
Date of Birth Address
_____________________________________ _________________________________________
Drivers License Number and State City State Zip

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