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Voluntary Candidate Questionnaire

Pager:

-

Cross street:

Social security #:

Are you a U.S. Citizen?

If n~tl what country are you from? 1'-'\ ~llO (l T"'\

When did you move to the U.S.?

90

o

Can you legally accept employment?

: Type of position desired (Check all that apply):

DNanny DBabyNurse DCook

DPersonal Assistant ~ousekeeper DButler

OHousehold Manager OEstate Manager OOther

Olive-in ~e-out

ll-time (30 or more hrs/wk) DPart-time (under 30 hrs/wk)

eng-term (1 year or longer) OTemporary (please specify)

Date available to start new position:

Salary desired:

$(gross=before taxes to $(net=after taxes)

Hours preferred: q ~ s- Hours unavailable:

In what cities would you consider working?

C-{T4

Voluntary Candidate Questionnaire

Would you be comfortable working with two clients who wanted to share your services?

Are you comfortable working with a parent/employer in the home?

Are you comfortable working with a single parent/employer?

Are you comfortable working in a home with pets?

Would you consider a position t at includes travel?

Would you be willing to occasionally work extra hours?

Would you be willing to do an occasional over-night?

Do you have any religious obligations, preferences or practices which would affect your job?

Your name:

If yes, please explain:

What duties are you willing to perform? {Check all that apply}:

DUght housekeeping ~omplete housekeeping

Ihildren's laundry amily laundry

roning

Mending

DCooking (for children) DCooking (for family)

IriVing children arpool

rocery shopping

rrand running

ersonal shopping DPurchasing children's clothing

How would you rate your cooking ability?

DBeginner

What type of food do you enjoy making?

DGardening ~omework help

DTyping

DFiling

;8lComputer data entry DHousehold bookkeeping

E1Petcare

DHousehold event planning

DChild related event planning DScheduling service personnel

DSupervising household staff DHiring household staff

DGourmet

Education Name of school and location Dates attended {to/from} Degree/Major courses of study
Highschool Mf)Q to /4'&'3- ~ 6 /)EQLLE.
( rTt-\ .
Technical, vocational,
business or training
College or University 'fC{CO C .11'-\ /q 'i' 6 .- jCfgJ EtzaF.
'y .
Graduate school Are you currently taking classes?

(

Additional course work, seminars, training or volunteer work:

Future goals:

,Jay o:

01

Voluntary Candidate Questionnaire

Your name:

test or X-ray:

Do you smoke? yes, specify amount

often}

Do you now, or have you ever been treated for a drug or alcohol

pain or pressure

pressure

yes, note insurance

Voluntary Candidate Questionnaire

Your name:

Employers are always interested in hearing more about you and your family. please be advised that the foHowing information does not determine your eligibility for employment and is disclosed voluntarily.

Partner's name: I ..

~ fJ\J.,)

DSingle o Divorced

DSeparated OWidowed

Marital status:

Partner's birthplace:

M. ~)(I[ CO

~ Age: ..tJ How long have you been together? A'7

,JliNilUA-,J ~ -L lr:. 'q lct Y""J "

. Occupationi' \ Current ~I?ployer: ." How long employed there?

c rfli U:C NSTfu cJ ~,..j 1 tV Er.,U c () rJ I <4 eo: y- .

If you have children:

. ~ .. . ... . . . . -

----

If you have young children, do you plan to bring them to work with you? DYes

o

If not, who will care for them while you are working?

vtOH.

Please tell us aboutthe family you grew up with:

Your father's occupation:

Your mother's occupation:

Your brothers and sisters:

Name

Age

Occupation

City

Please list a few of your hobbies and interests:

Please list the languages you speak fluently:

Your name: JJ t (,t)/l.J~ if'l b rj.J._

Voluntary Candidate Questionnaire

What types of activities do you enjoy doing with children?

Please share the reasons you enjoy working with children:

If you were hiring someone for the position of Nanny, what qualities would you look for?

How do you manage difficult behavior?

Is there any additional information you would like to share about yourself?

Do you playa musical instrument? DYes DNo

Do you swim? DYes

DNo

Are you registered with Trustline? DYes

DNo

When?

Are you CPR certified?

DYes DNo

When?

Expiration date:

What ages of children do you feel comfortable working with?

DInfant (under 1 yr.) DToddler (I yr. to Z yrs.

DPreschool (3 yrs. to 5 yrs.) DSchool age {6 yrs. to 10 yrs.}

DSchool age (10 yrs. to 13 yrs.) DTeenager (13 yrs. +)

How many children are you comfortable working with (at one time)?

Are you comfortable working with twins?

DYes DNo

Voluntary Candidate Questionnaire

Your name:

Number ofbedrooms:3 . Number of bathrooms:

Were there any other employees in the household?

Reason for leaving:

How did you find this position? (newspaper, agency, etc.):

llE£K.l;<Jt!'C .

May we call your employer?

for office use only DReference

Voluntary Candidate Questionnaire

Your name:

-----

Zip

Number of bedrooms: Number of bathrooms: 3

Were there any other employees in the household?

How did you find this position? (newspaper, agency, etc.):

Reason for leaving:;: I.

~\\_'\A~}J) 50

May we call your employer? ~s

DNo

~ ~~ \&n\Q[ Cl.o.&vW etQ4t< {;Q1SJ2

for office use only DReference

Voluntary Candidate Questionnaire

Your name:

Reason for leaving:

Other rooms: ..3 DYes

a

How did you find this position? (newspaper. agency. etc.):

May we call your employer?

tAts

DNa

for office use only DReference

Voluntary Candidate Questionnaire

Your name:

Work History

Job title:

End

Length of Employment:

Supervisor:

Phone:

code:

Hours worked: , .~

'b ',Dc;.;'

Starting salary Net:$

Gross:$

so~

Finishing salary Net:$

r-<, c$0 Gross:$ :) O"~

Duties:

«7

Cr l'eULf) Il-

How did you find this position? (newspaper, agency, etc.):

Reason for leaving:

May we call your employer?

kYes

DNa

for office use only DReference

Job title: Start date: End date: Length of Employment:
Employer/Company: Supervisor: Phone:
Address: City: State: Zip code:
Days worked: Hours worked:
Starring salary Finishing salary
Net:$ Gross:$ Net:$ Gross:$
Duties: How did you find this position? (newspaper, agency, etc.):

Reason or eaving:

May we call your employer? DYes

DNa

for office use only OReference

Voluntary Candidate Questionnaire

Your name:

Length of Employment:

Hours worked:

»-:

"r. Gross:$

Starting salary Net:$

Finishing salary Net:$

Duties:

How did you find this position? (newspaper, agency, etc.):

Reason for leaving:

May we call your employer?

for office use only DReference

Starting sala Net:$

Gross:$

Finishing sala~ c}...,;> Net:$ U--

Gross:$ ¥ 0 t:

Duties:

. i 'TCfI£;J

bA ,T // £,)1)1-(-..5

newspaper, agency, etc. :

Reason or eaving:

May we call your employer? ~s

DNo

for office use only DReference

Voluntary Candidate Questionnaire

Your name:

Landlord References {current and );!!_evious}:

Please describe your driving record:

Have you had any accidents or traffic DYes violations? ~

If so, please explain:

Have you ever been convicted of a

misdemeanor or felony? 0

If so, please explain {convictions do not necessarily disqualify you from employment}:

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Cut here anI! give form W .... 10 your empJoYBf, Keep the top

rDr your l'Oeili'd,>,

Employee's Withholding Allowance

OMS No. 1545-00'0

5 S 7

CDt. 10220Q

U.S. Department of Justice Immigration and Naturalization Service

OMa No. 1115·0136

Employment Eligibility VerificatIon

Please read Instructions carefUllY betor, completing this fann.·· 'rhe nstructton must be available during completiDn of this form. ANTI-DISCRIMINATION NOnCE'. It Is Illegal to dlscrl )nate aga sl work eligIble IndIviduals. Employers

CANNOT specify WhIch will accept from an emplo ea. Tho efusal 10 hire an Individual beenuso Of a

future expIration date dlscrlmlnallon.

Section 1. Employee InformatIon and Verification. To b(l oomplilioo

Print Name: Last

First

A.

am aware thai feefera) law pr'OVldes for Implisonment andlor fines for false statements or In connection with the

6m'lID"'1~r. E:w:arrllne ene documant from List A OR

the II lie, number and explratioll date, it any, of

Explration Pala (1/ ;my): _j_)_ Docul"nent#:

ExpIration Oala (ffany): _/.....J_

CERflFICATION • I aHast, under penalty of perjury. thllt I have

List C

\J.~'''':::'.: _

:s OC ft\L :')1: ~ ul.lT'li N Ill.\R2'lf..

List A

OR

DOt;um!:nt Utlll: _

Issuing authority; _

Document JI':

employes. that the above-listed documel')t(s) appear to be mUluirl1ll employee began employment On (montNday;year) _/......J._2fld

is eligible to work In the United Statas. (Slale employmel'1t aglinelos

8m .

presented by the above-named to the employee named. 1hl'rt the of my knowledge tho empiDyee omit the date the employee began

Businrn;. or OrganrzlItion Nama

Section 3. Updating and ReVerification. To be complBjDcl and l>Igned by

A. New Nams (if applfcOb/9j

(if Bpp/icobfo)

C. Jr employee's previous IIrant of work authorization has expired, provide the . eligibility.

Documen1

document thai astabllshea OUl'Ttlrlt employment

. .

(If nn'1);_)_)_

work In 1he Unlled Stales, and If the employee Ihs Individual.

Fonnl·9 (Rev, 11-21-91) N