Name |
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Email Address |
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| Street Address |
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| City, State, Zip Code |
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| Home Phone |
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| Work Phone |
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| Cell Phone |
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| Social Security # |
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| Date of Birth |
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| Driver's License State & Number: |
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| Name, Address & Phone Number of emergency contact (state relationship) |
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| When is the best time to reach you? |
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| When can you begin working? |
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| Can you legally accept employment in the US? |
(Y)-Yes (N)-No |
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| Have you ever been convicted of misdeameanor or felony? |
(Y)-Yes (N)-No |
| If yes, please explain: |
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| Do you smoke? |
(Y)-Yes (N)-No |
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| Do you have a valid driver license? |
(Y)-Yes (N)-No |
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| Do you own a car? |
(Y)-Yes (N)-No |
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| When was your last ticket or accident? Please explain: |
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| Has your license ever been suspended? |
(Y)-Yes (N)-No |
| If yes, please explain: |
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| What year did you graduate high school? |
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| Any additional schooling? |
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| Have you attended college? For how long and if you graduated, what year? |
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| What was your major? |
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| If you are relocating, why did you choose this area? |
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| Does your family support your relocating? |
(Y)-Yes (N)-No |
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| What are you looking for in terms of salary? |
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| What were you paid in your last job? |
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| Are you seeking full-time or part-time work? |
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| # of Hours |
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| What days/hours are you not available to work? |
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| Are you seeking permanent or temporary work? |
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| If happy, how long can you commit to staying with a family? |
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| Which living option are you seeking: |
(Live-in, Live-out, Either) |
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Describe your health status:
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(Excellent, Good, Fair, Poor) |
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| Any allergies or medications? |
(Y)-Yes (N)-No |
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| Are your immunizations up to date? |
(Y)-Yes (N)-No |
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Please be as open and complete as you can for the following questions as they will help us find the right family for you: |
| Why do you want to be a housekeeper? |
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| For each housekeeping experience please describe the dates of employment, ages of any children in the home, hours worked, and why you left the job: |
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| Tell us about your best experience with housekeeping. |
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| Tell us about your worst experience with housekeeping. |
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| What are you looking for in a job? (ie. Children, no children, relationship you want with your family) |
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| Do you have any experience with pets? Would you mind helping to take care of a family's pets? |
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| Do you have any pet allergies? |
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| Can you cook? Would you be willing to cook for the children/ the family? |
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| What other household duties would you be willing (or unwilling) to do? |
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| Tell us about your family (parents, siblings, children, their occupations/activities). |
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| Are you living with your family or on your own? |
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| Tell us a little bit about yourself. For example, how would your best friend describe you? |
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| What are your hobbies/interests? |
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| Describe your current job if you are employed. Why are you looking to change jobs? |
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| What are your future goals? |
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| Please list the names and phone numbers of at least 3 references for whom you have worked in housekeeping. If there are not three jobs like that, the references may be from other employers or academic areas. |
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| Is there anything else you feel a family should know about the qualities you have to offer their family? |
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