To Hire A Nanny__Housekeeper__Home Care Provider__Other__

This Application Form Will Print Out On Four Letter Size Pages.

Name ____________________________________________________________

Addr _____________________________________________________________

Home Tel # ______________________________Work _____________________

Fax Tel # _____________________________ Cell ________________________

Email Address(es) _________________________________________________

Seeking A Nanny, Housekeeper Or? _____________________ LiveIn/Out? __

Start Date (M/D/Y) _____________________ Full/Part Time? ______________

Specific Days & Hours Required _____________________________________

 If A Nanny is Required, Please State The Gender And Age of Each Child: 

________________________________________________________________

________________________________________________________________

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If Personal, Home Care, Elder Care, Etc. Is Required, Please Give Details:

Drivers Lic Req’d? ______ Vehicle Req‘d? ______ Vehicle Provided? ______

If Live In, Describe Living Quarters For Caregiver _______________________

Job Description: Duties, Type Of Caregiver Preferred, Other Comments:

IF YOU ARE APPLYING FOR GENERAL CARE GIVING SERVICES:

YOU WILL PAY NO REGISTRATION, APPLICATION OR REFERRAL FEES.

A CONTRACT FOR GENERAL CARE GIVING SERVICES IS OPTIONAL.

IF YOU ARE APPLYING FOR CAREGIVER REFERRAL SERVICES:

A CONTRACT IS REQUIRED. YOU WILL PAY A NON REFUNDABLE

APPLICATION FEE OF $250. UPON SUCCESSFUL PLACEMENT OF A

REFERRED CAREGIVER, YOU WILL PAY A SEPARATE NON

REFUNDABLE PLACEMENT FEE OF $250.00.

WITHIN CANADA = CDN $, OUTSIDE CANADA = US $

WE ACCEPT CASH, CERTIFIED CHECKS, TREASURERS CHECKS,

BANK DRAFTS AND BANK OR POSTAL MONEY ORDERS. IF YOU

ARE PAYING WITH AN UNCERTIFIED PERSONAL CHECK, THERE

WILL BE A WAITING PERIOD OF 15 DAYS FOR BANK CLEARANCE.