Family Helpers for Nannies, Babysitting, Child Care, Housekeeping

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Housekeeping

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Housekeeping Employment Application

Fill out the form below. The results will be sent to Family Helpers, Inc.

Referred By:
Full Name
Address 1
Address 2
City
State	Zip Code
Country
Phone Numbers	Day Evening
email
Are you a citizen or have proof of eligibility to work in the US (required)? Yes No Position applied for: Salary Requirement: What position are you seeking? Live-in Live-out Full Time or part Time? Full-Time Part-Time Are you 18 years of age or older? Yes No Emergency Contact: Contact Phone: Relationship to Contact: When can you begin working: Are you willing to committ to one year employment (necessary)? Yes No Have you ever been convicted of a felony? Yes No If yes, explain: (The existence of a criminal record is not an absolute bar to employment.) Experience What kind of housekeeping experience do you have (no. years, commercial, residential, etc.) Please list the last 2 jobs you held. Give a brief description of job duties.
Dates (from - to)
Employer Name
Phone # (with area code)
Supervisor's Name
Describe job duties:
Dates (from - to)
Employer Name
Phone # (with area code)
Supervisor's Name
Describe job duties:
May we contact your previous employers? Yes No
Why did you leave your last job?
Would you be willing to do heavy housework? Yes No
How many years of child care experience do you have?
Which of the following would you be willing to do?
Errands	Yes No
Ironing	Yes No
Children's Laundry	Yes No
Family Laundry	Yes No
Children's Cooking	Yes No
Family Cooking	Yes No
Childcare	Yes No

Do you speak fluent English?	Yes No
Do you have any special interests, hobbies or talents? Please list:
Will you work in a home with a dog? Yes No
Will you work in a home with a cat? Yes No
If yes, would you help care for pets? Yes No

Health
Do you smoke?	Yes No
Do you use recreational drugs?	Yes No
Do you have any allergies?	Yes No
If yes, please explain.
Are you able to lift up to 30 lbs.? Yes No
If no, please explain.
Do you suffer from any conditions that would impair your ability to work? Yes No If yes, please explain.
Would you consent to getting a physical exam & drug screening? Yes No
Date of your last physical exam.

Driving Record
Do you drive?	Yes No
Do you have a car?	Yes No
Driver's License Number? State:
Has your license ever been suspended or revoked? Yes No If yes, please explain.
Heve you had a traffic ticket in the past 5 years (not parking)? Yes No If yes, please explain.
Have you had an accident while driving a car in the past five years? Yes No If yes, please explain.

Education
Education level
Do you have any special housekeeping training or education? Yes No If yes, please describe.

References
Please provide 3 references, 1 personal and 2 housekeeping related.
Reference - Personal
Name:
Phone:
Address:
Realtionship to you:

Reference - Housekeeping Related
Name:
Phone:
Address:
Realtionship to you:

Reference - Housekeeping Related
Name:
Phone:
Address:
Realtionship to you:

For Live-in Positions Only
Have you ever lived independently from your family? Yes No

Agreement and Certification:
I certify that the above information is true and complete. I agree to having Family Helpers, Inc. ("FHI") or their authorized agents investigate any of the above information. I further agree to fully cooperate with those efforts including the provision of additional information and required releases. I understand that by accepting this application from me, FHI makes no guarantee of employment. FHI assumes no liability or responsibility to confirm or verify all information supplied to it by any employer or potential employer. I agree to hold FHI harmless from any act, failures to act, or omissions by any employer or potential employer, referred to me, or to whom I am referred, by FHI. I agree to notify FHI within 7 days of receiving an offer of employment by any such party, and should such party then fail to pay FHI its usual fee, then I agree to pay FHI the maximum fee allowed by New York State General Business Law Article !! Section 185. This agreement shall be binding only upon the parties hereto and shall not include any third party. FHI shall not be a party to any agreement entered into between Applicant and any employer or potential employer. Yes No We are an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law.