Premier Domestic Staffing – Domestic Help and Nanny Services

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Home > Prospective Candidates > Preliminary Application

Prospective Candidate Application

If you feel you meet or exceed our minimum requirements please complete the following preliminary application and forward your current resume to . We look forward to helping you!

Tell us about you!


First name:	M.I.:		Last name:
Address:			Street:
City:			State:
Zip:			Apt./Unit #:
Home phone:			E-mail:
Work phone:			Cell #:
Available Start Date:		Position applied for:
Desired Salary: $		Emergency Contact(s):		Name and Address:
Birth date:(optional)
Marital status: (optional)
Do you have children? If yes, names & ages:

Are you a citizen of the United States?		If no, are you authorized to work in the U.S.?
Have you ever been convicted of a felony?		If yes, explain:
Do you drive?		If yes, year and make/model of automobile:
Do you have anything on your driving record for the past 7 years?:

SKILLS: (Select all that you are willing to do)
Cleaning
Floors
Laundry
Ironing
Cooking
Childcare
Errands
Grocery Shopping

CHILDCARE SKILLS:
Do you have favorite ages of children?
How many children are you comfortable caring for?
Are you willing to do carpooling?
Do you swim?
Are you CPR and First-Aid certified?
Do you like pets?

How did you hear about Premier Domestic Staffing?
Personal Reference
Yellow Pages
Web Search?
Which Search-Engine?
Which Phrase?
Are you registered with another agency?

HEALTH INFORMATION
Do you smoke?
Have you had a physical exam in the past year?
Do you have any allergic conditions (such as cats or dogs that we need to be away of)?
If Yes, please explain
Do you have any physical conditions that will affect your job performance?

Education


High School

Name:		Address:
From:		Did you graduate:
To:		Degree:

College

Name:		Address:
From:		Did you graduate:
To:		Degree:
Major:		Minor:

Other

Name:		Address:
From:		Did you graduate:
To:		Degree:
Major:		Minor:

Previous Employment

Please do not leave gaps in employment history.
Company:		Phone:
Address:		Supervisor:
Job Title:		Email Address:
Responsibilities		Reason for leaving:
From:
To:
May we contact?

Company:		Phone:
Address:		Supervisor:
Job Title:		Email Address:
Responsibilities		Reason for leaving:
From:
To:
May we contact?

Company:		Phone:
Address:		Supervisor:
Job Title:		Email Address:
Responsibilities		Reason for leaving:
From:
To:
May we contact?

Childcare/Domestic References

*Please list three references. Do not list family or friends.*

Full Name:		Relationship:
Company:		Phone:
Ages of children cared for:		E-mail:
Reason for Leaving:

Full Name:		Relationship:
Company:		Phone:
Ages of children cared for:		E-mail:
Reason for Leaving:

Full Name:		Relationship:
Company:		Phone:
Ages of children cared for:		E-mail:
Reason for Leaving:

Please describe why you are seeking a childcare/domestic position at this time.

All answers provided both in this application and given during any interview are true, correct and complete, and that I have not omitted any information. If any answer is found to be false or misleading, any employment will be immediately terminated.