Please fill out this form and we will get in touch with you shortly. Name* First Last Spouse Name First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Alternate PhoneFaxBest time to call: Email Your EmploymentOccupation Place of Employment Work PhoneCell PhoneEmail Spouse EmploymentOccupation Place of Employment Work PhoneCell PhoneEmail Emergency ContactEmergency Contact Name First Last Emergency Contact PhoneDo any other family member or friends live in your home? (children, grandparents, aunts, uncles, etc) Yes No If yes, please explain:Does anyone in your home smoke? Yes No Start Date Requested MM slash DD slash YYYY Kind of Service: Salary Offered: Required hours and days: What skills and abilities would you like to have in your employee?Will your employee need to drive you or your children/elderly/pet? Yes No If yes, will your employee need to supply a car? Yes or Will you supply a car? If you are supplying the car, is it manual or automatic? Manual Automatic Duties your Household Manger will be responsible for: Click all that apply Organizing Meal Planning Arranging Appointments Booking Travel Arrangements Greeting and Serving Guests Errands (shopping, gift purchases, dry cleaning) Managing the Household Calendar Household Bookkeeping and/or Accounting Tasks Plan/Direct Special Projects Hiring & Supervision of Other Household Staff or Contractors (Nanny, lawn, pool, and cleaning) Occasional Childcare Secretarial Responsibilities Does your Household Manager need excellent computer capabilities? Yes No Do you require the employee to cook for: Children Elderly Family All of the Above None of the Above Do you require the caregiver to do laundry for: Children Elderly Family All of the Above None of the Above What other kinds of errands would you like your employee to do? (pick-up/drop-off kids from activities, pick-up prescriptions, take pet to vet, drop of dry cleaning, etc)Do you have any other comments at this time that you feel you should add?How did you hear about Nanny Nexus? Nanny Nexus Services Client Understanding and Release:Understanding between parties: 1. Nanny Nexus agrees to make its best effort to locate an employee for client's household needs on requested basis. 2. Client agrees to pay caregivers directly for services rendered at least. 3. Client understands that the services provided by all caregivers referred by The Agency must be contracted through The Agency office. Client further understands that the use of an Agency caregiver, or referral of an Agency to a third party, without arranging the visit through the agency, is considered "theft of services" and will result in a charge of $2,500 for liquidated damages. 4. In the event that Client wishes to hire someone referred by Nanny Nexus on a permanent basis client agrees to pay Nanny Nexus placement fee for a permanent Caregiver ("Household Manager") is $1,600 . Client understands that caregivers working with Nanny Nexus are not employees of Nanny Nexus. Client understands that if they pay more than the allotted government amount per calendar year to anyone caregiver s/he is responsible for withholding and filing employment taxes for that person. Social Security number of caregivers must be obtained directly from caregivers. 5. Client agrees to forever indemnify, release and hold harmless Nanny Nexus its agents, employees, and officers for any and all claims relating to services provided by caregivers. By typing your name and submitting the form as completed above, you agree that you have read and agree with the information on this form. You also agree to comply with it, and agree to pay any applicable fees, listed above. Full Name* Date Application Completed Month Day Year * I agree that all of the information on this application is true to the best of my knowledge.