Quality Care

A Full Service Nanny Placement Agency

Preliminary Nanny Application
Name	E-mail Address(required)
Street Address	City, State, Zip Code
Cell Phone Number	Date of Birth:
Work Schedule
Are you looking for: Full Time Part Time Live with Family Live Out
Do you have a preference for where you work? Yes No
If Yes, please give details below:
Background Information
Please give some details about your most recent child care experience (s).
Please give some details about the ages of the children for whom you cared.
Please provide an employer reference (Name and Phone Number)
Have you ever been convicted of a misdemeanor or felony? Yes No If yes, explain
Do you:
Have a Valid Driver License: Yes No
Own a Car: Yes No
Has your license ever been suspended? Yes No If yes, explain
Do you have any credit problems? Yes No
If Yes, please explain:
Why does nanny work appeal to you?
What is your salary range?
Is a one year commitment possible? Yes No If no, why?
If you are satisfied, how long would you be willing to stay in a nanny position? Years
My health can be described as: Excellent Good Fair Poor
Please explain any health problems you are experiencing.