Family Helpers for Nannies, Babysitting, Child Care, Housekeeping

Applications

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Housekeeping

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Companion Application Form

Referred by: Date:

Name:

Street Address:

City: State: Zip:

Day Phone: Evening Phone:

Email:

GENERAL INFORMATION:

Are you eligible to work in the U.S.? YesNo

Are you seeking a live-in or live-out position? Live-inLive-out

Salary Requirement:

Full-time or part-time? Full-timePart-time

When are you available to start a position?

Are you 18 or older? YesNo If not, state your age:

Emergency Contact:

Relationship to you: Telephone:

A minimum commitment of one year is necessary. Can you commit to this? YesNo

Have you ever been convicted of a felony? YesNo

(The existence of a criminal record is not an absolute bar to employment.)

What are your strengths?

What are your weaknesses?

List the last 3 jobs you have held along with the start and end date of each and the responsibilities.

DATES	EMPLOYER	ADDRESS	PHONE
1. -
2. -
3. -

May we contact your previous employers? YesNo

Why did your last position end?

Would you be willing to do light housework?YesNo Heavy Housework?YesNo

Laundry?YesNo, Cooking?YesNo, Errands?YesNo, Ironing?YesNo

Would you be willing to help client bathe? YesNo

What languages do you speak? Read?

Have you ever had a medical emergency while caring for someone? YesNo

If yes, please explain how you handled it?

If no, how would you handle a medical emergency?

Would you work in a home with animals? YesNo

If yes, would you help care for the animals? YesNo

Do you have any special interests or hobbies?

HEALTH:

Do you smoke? YesNo

Do you use recreational drugs? YesNo

Do you have any allergies? YesNo

If yes, please specify?

Are you physically able to lift up to 30 lbs? YesNo

Do you suffer from any conditions that would impair your ability to work?

Consent to getting a physical exam & drug screening before beginning work? YesNo

Date of last physical exam?

DRIVING RECORD:

Do you drive?YesNo Standard (stick)?YesNo Automatic?YesNo

If yes, do you have a car to get to work? YesNo

Will you drive the client to appointments? YesNo

How long have you been driving?

Has your driver's license ever been suspended or revoked? YesNo

If yes, please explain when and why?

Have you ever had a traffic ticket (except parking) in last 5 years? YesNo

If yes, what were the tickets for?

Have you had an accident while driving a car in the last 5 years? YesNo

If yes, please explain?

EDUCATION:

What was the last grade you completed in school?

Have you taken any training to be a companion? YesNo

If yes, please list?

Is there anything you can tell us about yourself that may help place you as a companion?


ADDITIONAL REFERENCES:	*Please list 4 references, 1 personal, 3 job-related.*

Reference 1 - Personal:
Name: Address:
Phone: Relationship to you:

Reference 2 - Job Related:
Name: Address:
Phone: Relationship to you:

Reference 3 - Job Related:
Name: Address:
Phone: Relationship to you:

Reference 4 - Job Related:
Name: Address:
Phone: Relationship to you:

FOR LIVE_IN POSTIONS ONLY:

Have you ever lived independently from your family? YesNo

Do you have siblings?YesNo If yes, please specify ages?

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 and verify all information supplied to it by any employer or potential employer. I agree to hold FHI harmless from any acts, 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 from any party referred to me by, or to which I am referred by FHI. Should I fail to so notify FHI and should I then accept 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 11 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.

I understand that clicking on the SUBMIT key is the equivalent of signing this document.

(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.)