Application to Become a Nanny Nexus Nanny

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Preferences

Applicants must be able to make a one-year commitment for a permanent placement.

List

Date 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:

Please check the family situations that you would be willing to work in:

Working Mother
Single Mother
Non-working Mother
Mohter 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:

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. Highschool

School:

Location:

Yrs Attnd	Date Graduated:

Degree:

2. College

School:

Location:

List

Yrs Attnd:	Date Graduated:

Degree:

3. Other

School:

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 #1

From:	To:

Family or Organization:

Length of time/frequency:	Ages of children:

Address:

Home Telephone #:	Work Telephone #:

Childcare Experience #2

From:	To:

Family or Organization:

Length of time/frequency:	Ages of children:

Address:

Home Telephone #:	Work Telephone #:

Childcare Experience #3

From:	To:

Family or Organization:

Length of time/frequency:	Ages of children:

Address:

Home Telephone #:	Work Telephone #:

Childcare Experience #4

From:	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.

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