First Steps Agency, Inc.

Nanny Preliminary Application

Personal Information

Name:

Address:

City:

State:

Zip:

Phone (day):

Phone (evening):

Cellular Phone:

E-Mail Address:

Work Preferences

Are you looking to work?:

Are you willing to work in?:

What days/hours are you willing to work?:

When can you start working?:

Response (Yes/No)/Explanation

Do you know how to drive?

Do you have a valid driver’s license? If yes, provide license number and state.

Do you have any moving violations? If yes, list dates/reason for ticket.

Have you ever had your license revoked? If yes, explain.

Have you ever been involved in a car accident as driver or passenger? If so, explain.

Do you have any credit problems? If yes, explain.

Do you have an active credit card?

Do you have first-aid training? If yes, last date updated.

Do you have CPR training? If yes, last date updated.

Do you have any health problems that might affect your job performance? If yes, please explain.

Have you ever been arrested? If yes, explain.

Have you ever been convicted of a felony? If yes, please explain.

Childcare Experience/Employment Please list the childcare positions you’ve held in the last 5 years. List your most recent employer first.
Employer name/address/ phone number	Dates from-to (give month /year)	# of hours worked per week	Duties	Children’s ages when you left	Salary when you left	Reason employment ended

Other information you would like us to know: