|
|
| Who
were you referred by? |
|
| Name |
|
| Address
1 |
|
| Address
2 |
|
| Address
3 |
|
| City |
|
| State |
|
| Zip/Postal
code |
|
| Country |
|
| Phone
Numbers |
Day
Evening |
| E-mail |
|
|
General
Information
Are you a
citizen or have proof of eligibility to work in the US? Note:
this is 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?
A minimum
commitment of one year is necessary. Are you able to commit to
one year employment?
Yes
No
Have you ever
been convicted of a crime?
Yes
No
If yes to
above, explain:
Experience:
What kind of housekeeping experience do you have? (# of 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
worth 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.
|
| Can
you work in a home with pets?
Yes
No |
| If
yes, would you help care for pets?
Yes
No |
|
|
| Health |
|
| Do
you smoke? |
Yes
No |
| Do
you drink alcohol?
Yes
No |
| If
yes, how much do you consume?
|
| Do
you use recreational drugs?
Yes
No |
|
Do you have
health insurance?
Yes
No
Do you
expect it to be provided?
Yes
No
|
Are
you on any medication?
Yes
No
If yes, please explain.
|
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 with drug screening before
beginning work?
Yes
No |
| Date
of your last physical exam.
|
Date
of most recent TB exam.
Results
Positive
Negative |
|
|
| Driving
Record |
|
| Do
you drive? |
Yes
No |
| Driver's
License Number
State
|
Has
your license ever been suspended or revoked?
Yes
No
If yes,
please explain.
|
Have you had a traffic ticket in the past 5 years (not parking tickets)?
Yes
No
If yes,
please explain.
|
Have you been driving a car that has been in an accident in the
past five years?
Yes
No
If yes,
please explain.
|
|
|
| Education |
| Education
level |
|
Do
you have any special housekeeper training or education?
Yes
No
If yes, please describe.
|
| For
Live-in Positions Only |
|
Have you ever
lived independently of your family?
Yes
No
References
Please provide
3 references, 1 personal and 2 housekeeping related.
Reference
- Personal
|
|
Name
|
|
| Phone |
|
| Address |
|
| Relationship
to you |
|
| Reference
- Housekeeping related |
|
Name
|
|
| Phone |
|
| Address |
|
| Relationship
to you |
|
| Reference
- Housekeeping related |
|
Name
|
|
| Phone |
|
| Address |
|
| Relationship
to you |
|
|
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
|
|
|
