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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


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
Address
Phone # (with area code)
Supervisor's Name

Describe job duties:



Dates (from - to)

Employer Name
Address
Phone # (with area code)
Supervisor's Name

Describe job duties:



May we contact your previous employers? Yes No

Why did your last position end?



Would you be willing to do heavy housework? Yes No

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

How many years of child care experience do you have?
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:

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.

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