First Name * Middle Initial *

Last Name *

Address: City*
Street *
Apt#

State * Zip *
E-Mail *

Previous address: * City
Street * Apt#

State* Zip*
Date of Birth*

Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 0 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
Age*
Marital Status *
Married Single

Phone * Cell

Driver License No * State
Can you provide reliable transportation? *
Yes No
Do you have auto insurance? *
Yes No
Insurance Company?*

Do you have any accidents and violations in past 5 years? *
Yes No
If Yes, List and Explain

Have You Ever Been Arrested or Convicted of a Crime? *
Yes No

If Yes, List and Explain:

Have You Used Illegal Drugs? *
Yes No
If Yes, List and Explain
How long have you been in the United States? *

Nationality:
Religion:
Legal Status: *
Student Visa
Work Permit
Green Card
USA Citizen
You are applying for: *
Full-Time
Part-Time
On-call
Days
Morning
Afternoon
Evening
Night
Mon
Tues
Wed
Thus
Fri
Sat
Sun

From To

Which language(s) do you speak and understand? *

Please list any allergies you have

Which of the following courses have you taken? (check all that apply)
Nanny
Home Aid
CNA
Childcare
First Aid
CPR

You are looking to be a caregiver, babysitter or a housekeeper? (check all that apply) *

Babysitter
Caregiver
Housekeeper

Do you know how to swim?
Yes No

What is your general health condition? *
Excellent Good Poor

Your energy level?
High Average Low
Please list any psychological problems you may have *

Please list any medications you take and what you're taking them for: *

Are you able to travel domestically?
Yes No

Are you able to travel internationally?
Yes No

Will you work if there is a cat? *
Yes No

Will you work if there is a dog? *
Yes No

Do you like to cook?
Yes No

Have you ever worked as a housekeeper in a household?
Yes No

Why do you want to be a babysitter?

Why do you want to be a caregiver?

Which of the following ages do you have experience? *
Newborn
6-24months
2-5 years
6-12 years
Teenagers

Have you raised children of your own?
Yes No

Are any of your children currently residing in the United States?
Yes No

Have you ever had experience with children with special needs or handicaps?
Yes No

Have you ever had experience with any of the following condition as a caregiver? (check all that apply) *

Cancer
Dementia/Alzheimer's
Diabetes
Bone Fracture
Arthritis
Acute/Terminal Care
Heart Condition
Hospice
Paralysis
Parkinson's
Rehab
Incontinent
Stroke
Kidney/Dialysis
Hoyer Lift
Wheelchair
Other

EDUCATION

HOBBIES & INTERESTS

WORK HISTORY

CHILDCARE REFERENCES

1. Current or Last Employer Name, Address, and Phone Number: *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

2. Previous Employer Name, Address, and Phone Number *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

3. Previous Employer Name, Address, and Phone Number: *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

CAREGIVER REFERENCES

1. Current or Last Employer Name, Address, and Phone Number *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

2. Previous Employer Name, Address, and Phone Number: *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

3. Previous Employer Name, Address, and Phone Number: *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

HOUSEKEEPING REFERENCES

1. Current or Last Employer Name, Address, and Phone Number *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

2. Previous Employer Name, Address, and Phone Number *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

3. Previous Employer Name, Address, and Phone Number *

Dates Employed:
From To

Please give a brief description of your job requirements

Reason(s) for Leaving

PERSONAL REFERENCES

1. Name, Address, and Phone Number *

2.Name, Address, and Phone Number *

3. Name, Address, and Phone Number *

I am Enclosing The Following (copies), Reference, Certificates, Documents, Photos, Etc:

Do you have a physical exam made less then a year? *
Yes No

If you check No above GO to Forms and Print Physical Exam Form Please!

Desired Salary per Day
Desired Salary per Hour

How did you learn about Smile & Love Inc.? (check all that apply)
Newspaper
Friend
Internet
Social Worker
Flyer
Business Card
Referral
Other

AUTHORIZATION
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information."

SIGNATURE
DATE