Employer Application Employer Application In order to submit form you must complete all required fields. Please check to make sure all required fields have been completed prior to submitting. Please also complete and submit Employer Agreement at same time. Thank you. Step 1 of 7 14% Mother's NameMother's OccupationWork PhoneMobile PhoneFather's NameFather's OccupationWork PhoneMobile PhoneHours away from homeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneEmail CHILDRENNumber of childrenChild 1 Name First Last Child 1 GenderFemaleMaleChild 1 Age1-6 months6-12 months1 year2 year3 year4 year5 year6 year7 year8 year9 year10 year11 year12 year13 year14 year15 year16 year17 yearChild 2 Name First Last Child 2 GenderFemaleMaleThird ChoiceChild 2 Age1-6 months6-12 months1 year2 year3 year4 year5 year6 year7 year8 year9 year10 year11 year12 year13 year14 year15 year16 year17 yearChild 3 Name First Last Child 3 GenderFemaleMaleChild 3 Age1-6 months6-12 months1 year2 year3 year4 year5 year6 year7 year8 year9 year10 year11 year12 year13 year14 year15 year16 year17 yearChild 4 Name First Last Child 4 GenderFemaleMaleChild 4 Age1-6 months6-12 months1 year2 year3 year4 year5 year6 year7 year8 year9 year10 year11 year12 year13 year14 year15 year16 year17 yearChild 5 Name First Last Child 5 GenderFemaleMaleChild 5 Age1-6 months6-12 months1 year2 year3 year4 year5 year6 year7 year8 year9 year10 year11 year12 year13 year14 year15 year16 year17 yearChild 6 Name First Last Child 6 GenderFemaleMaleChild 6 Age1-6 months6-12 months1 year2 year3 year4 year5 year6 year7 year8 year9 year10 year11 year12 year13 year14 year15 year16 year17 yearDo any of your child(ren) have special needs?NoYes(If yes, please descibe) Position offered isFull-time Live InFull-time Live OutPart-TimePermanentSummer PlacementTermporaryDo you live in aHouseCondoTownhouseApartmentDoes anyone else live in the home other than individuals listed above?YesNo(if Yes, please indicate name, age and if they will be in the home during the nanny's hours)Dates you need a nanny:From To Please indicate nanny's hours and days off:MondayTuesdayWednesdayThursdayFridaySaturdaySundayVarious Will your nanny be driving?YesNoIf Yes, and vehicle is provided, what restrictions and responsibilities will you expect of your nanny?If Yes, is vehicle automatic or manual (clutch)?AutomaticManual (clutch)If your nanny's own car is required for use, what reimbursement arrangements will be made?If driving children, please indicate all required. To school From school To activities From activities To friends' house Fro friends' house What is your policy regarding your nanny receiving visitors, phone calls, using the television, etc.?(Please be specific.)Will your childcare needs differ during school vacations and holidays?YesNoIf Yes, please explain:Will you provide your nanny living space?YesNoIf Yes, please describe:Will you provide a private bedroom and/or bath?YesNo What is the salary range for your nanny?Monthly range:From*ToWeekly range:FromToHourly:From*To*How often will your nanny be paid?MonthlyWeeklyDailyPlease indicate any benefits you will offer your nanny: Medical Dental Vacation Sick leave Please describe any other benefits you will offer your nanny: Will your nanny be required to do housework?YesNoIf Yes, what housework duties? Children's rooms Master bedroom Laundry Mopping Vacuuming Dusting Misc. Will your nanny be responsible for cooking/preparing meals?YesNoIf Yes, what meals? Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening Snack Do you have a family pet?YesNoIf Yes, what type of pet?Pet nameWill the nanny be responsible for the pet's care?YesNoPlease describe what your nanny's primary responsibilities will bePlease describe what a typical day will be like for your nannyPlease indicate any additional comments, concerns or special situation or needsPlease provide two character references:#1 Reference Name First Last Phone#2 Reference Name First Last PhoneBy clicking Submit I agree that I have completed this application as accurately and precisely as possible. I also have read and agree to the terms in the Employer-Agency Agreement. I understand that any of the aforementioned references can and will be contacted for verification of this information.Name First Last Date EmailThis field is for validation purposes and should be left unchanged. Δ