Application to Become a Nanny Nexus Nanny Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Present Phone:Permanent Phone:Work Phone:Best time to call: Can we call you at work? Yes No Email Are you eligible to work legally in the US? Yes No Best time for an interview? In case of an emergency who should we contact? First Last Emergency Contact's Phone Number:Placement PreferencesApplicants must be able to make a one-year commitment for a permanent placement.ListDate you could begin work:Salary Request:Would you consider staying longer than one year? Yes No What are you currently doing? Why are you making a change?Please check job opportunities that you would be interested in: Nanny Full-time Nanny Part-time Summer Nanny Pet Care Compassionate Companion Mother's Helper Childcare Overnights Group Care Childcare Call-in Handyman Please check the family situations that you would be willing to work in: Working Mother Single Mother Non-working Mother Mother Working in Home Working Father Single Father Non-workin Father Father Working in Home Please check the ages of children that you would like to work with: Newborns (0-6 months) Infant (7 months-1 year) Toddler (1- 2½ years) Preschool (2½-6 years) School age (6+ years) All of The Above What is your favorite age group to work with? Do you have experience with newborns? Yes No What is the maximum # of children you would care for? Check the following that you would care for: Multiples (twins, triplets) ADHD Handicapped Special Needs Do you have a fear, dislike, or allergies to pets? Yes No If yes, tell us about it:How would you prefer your employer's home to be? Meticulously Very Neat Average No Preference Driving Background:Do you drive? Yes No If yes, how long have you been driving? Can you drive a stick shift? Yes No Will you drive your own car or will you require the use of a family car? Own Car Family Car If using your own car, what is the:Year:Make:Model:What is your driver's license #: Exp. Date: MM slash DD slash YYYY State license is issued in: In the last 5 years have you had a license issued in another state? Yes No If yes, what state(s): Do you have any speeding tickets, any other motor vehicle violations, been in a car accident that you received a ticket for, or had you license suspended? Yes No If yes, tell us about it:Personal Background:Have you ever been arrested found guilty for a crime? Yes No If yes, tell us about it:What are your future goals professionally?What are your future goals personally?Besides a nanny opportunity are there any other jobs you are currently pursuing?What are your hobbies and interests? Do you speak a foreign language? Yes No If yes, which one(s): Do you have any visible tattoos or piercings? Yes No Do you swim? Yes No Do you cook? Yes No If yes, tell us about your level and desire to cook:Did you experience any form of neglect of abuse as a child? Yes No If yes, please explain:What did you enjoy most about your parents' parenting skills?What are your personal strengths?What are your personal weaknesses?Education:1. HighschoolSchool:Location: Yrs AttndDate Graduated:Degree: 2. CollegeSchool:Location: ListYrs Attnd:Date Graduated:Degree: 3. OtherSchool:Location: Yrs Attnd:Date Graduated:Degree: Major(s) Studied: List any extra- curricular activites in highschool and/or college: Are you currently attending college? Yes No Nanny Experience:Tell us about any early education classes or experiences that you have had:Have you been a nanny before? Yes No If yes, how many times? Are you CPR or First Aid certified? Yes No If not, are you willing to be? Yes No If yes, can you provide proof? Yes No Childcare Experience (start with present or last position):Childcare Experience #1From:To:Family or Organization: Length of time/frequency:Ages of children:Address: Home Telephone #:Work Telephone #:Childcare Experience #2From:To:Family or Organization: Length of time/frequency:Ages of children:Address: Home Telephone #:Work Telephone #:Childcare Experience #3From:To:Family or Organization: Length of time/frequency:Ages of children:Address: Home Telephone #:Work Telephone #:Childcare Experience #4From:To:Family or Organization: Length of time/frequency:Ages of children:Address: Home Telephone #:Work Telephone #:Other Employment:Other Employment #1:From:To:Employer: Job Description: Supervisor: First Last Phone:Other Employment #2:From:To:Employer: Job Description: Supervisor: First Last Phone:Other Employment #3:From:To:Employer: Job Description: Supervisor: First Last Phone:Other References (other then child care, friends, or relatives):Reference #1:Name:Relationship To You: Home Phone:Work Phone:Reference #2:Name:Relationship To You: Home Phone:Work Phone:Reference #3:Name:Relationship To You: Home Phone:Work Phone:* I agree that all of the information on this application is true to the best of my knowledge. I CERTIFY THAT THE ANSWERS GIVEN HEREIN AND THE INFORMATION PROVIDED ARE FACTUAL, TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT FALSIFICATIONS, OMISSIONS OR MISREPRESENTATIONS MAY BE CAUSE FOR REJECTION OF MY APPLICATION TO Nanny Nexus LLC. OR ANY OF ITS CLIENTS, AND IF EMPLOYED BY A CLIENT OF NANNY NEXUS LLC. MAY BE CAUSE FOR IMMEDIATE DISMISSAL IF DISCOVERED AFTER MY EMPLOYMENT. I AUTHORIZE INVESTIGATION OF ALL INFORMATION CONTAINED IN THIS APPLICATION AND ANY SUPPLEMENTAL MATERIAL SUPPLIED BY ME AS MAY BE NECESSARY. I FURTHER AUTHORIZE ANY EMPLOYER, PERSON, CORPORATION, OR EDUCATIONAL INSTITUTION LISTED HEREIN, INCLUDING NANNY NEXUS LLC, TO ANSWER ANY AND ALL QUESTIONS AND AGREE TO HOLD ALL PERSONS HARMLESS FOR PROVIDING ANY AND ALL INFORMATION WITHIN THEIR KNOWLEDGE OR RECORDS. Electronic Signature: By selecting submit, you hereby verify that the above information is accurate. If not, please select cancel. Δ
