Please fill out this form as completely as possible to rush approval of your application. Please keep your answers brief and concise. You will have more opportunities to present a more detailed resume later.

Personal Contact Information: First Name:  Last Name:  Current Address:  City:  State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesee Texas Utah Vermont Virginia Washington West Virginia Wisconson Wyoming Zip Code:  Work Phone:  Home Phone:  Social Security #:  Age:  Date of Birth:  (mm/dd/yyyy) American Citizen:  Yes  No Sex:  Male Female Fax:  Your E-mail:  Repeat Your E-mail:

Emergency Contact Information: Name:  Relationship:  Street Address:  City:  State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesee Texas Utah Vermont Virginia Washington West Virginia Wisconson Wyoming Zip Code:  Work Phone:  Home Phone:  Fax:  E-mail:

Job Information:

Geographic Areas Preferred: 1.  2.  3.  Available Starting Date:  Requested Salary:  Position Desired:   Nanny - Live in  Nanny - Live out Do you want a permanent full-time position  (at least one year?)   Yes No Do you want summer work only?   Yes No Ages of children you have previously cared for:  Ages of children you would like to care for:  How many children have you cared  for at one given time?  Would you work in a single parent home?   Yes No Would you work in a home with pets?   Yes No Do you prefer to work in a home  where the mother works?   Yes No Are you willing to do housework  for additional money?   Yes No How do you rate yourself as a cook?   Good Fair Poor Will you prepare meals for the entire family?   Yes No Who referred you to our online application?  Search engine results Another site Friend Relative Just browsing Advertisment

Personal Information:

What Are you Currently Doing for employment?
Do you live with your parents?	Yes No
Parent's Names:
Parent's address:
Parent's address(s):
Mother's occupation:
Mother's phone number:
Father's occupation:
Father's phone number:
Number of brothers:
Number of sisters:
Where do you fit in?:	oldest youngest middle twin
Have you ever had children?	Yes No
Marital Status:	Single Married Divorced Widowed
Any involvement with youth organizations?
Do you have any experience with handicapped  or special needs children?	Yes No
If yes, please explain:
Are you certified in CPR?	Yes No
Are you certified in First Aid?	Yes No
Can you swim?	Yes No
Are you certified in lifesaving?	Yes No
Do you drive?	Yes No
Will you bring a car with you?	Yes No
Year/Make:
Driver's License Number:
State of license:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesee Texas Utah Vermont Virginia Washington West Virginia Wisconson Wyoming
Can you operate a stick shift?	Yes No
Have you ever had any traffic accidents or traffic tickets?	Yes No
If yes, please explain:
Have you ever been arrested?	Yes No
If yes, please explain:
Have you ever been convicted of any crime?	Yes No
If yes, please explain:
Height:
Weight:
Hair Color:	options BrownBlondeBlackRedGrayWhite  *optional
Eye Color:	options BlueBrownBlackGreenGrayViolet  *optional
Ethnic Origin:	*optional
Religious Affiliation:	*optional

READ CAREFULLY BEFORE SUBMITTING:

I certify that all of the information included in this application is accurate to the best of my knowledge. I understand that knowingly withholding information or providing false information is grounds for immediate dismissal from employment.

Please click the submit button now to enter this information and go on to part two. Please click only once. It takes a minute for your form to process.

END PART ONE

All-American Nanny, Ltd.