Village Nannies Job Application Form
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5VILLAGE NANNIES
APPLICATION FORM
DATE: ________________________________
GENERAL INFORMATION
Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Date of Birth:
Social Security #/Social Insurance #:
DRIVING RECORD
Do you have a valid driver’s license? Yes No
License #:
State/Province:
Number of accidents/moving violations in which you were a driver in the past 3 years: ___________
Explain:
Are you able to drive a manual transmission?
Do you have your own car?
Yes No
Yes No
MISCELLANEOUS
Have you ever been convicted of a crime? Yes No
If Yes, explain:
Do you smoke?
Do you take drugs?
Do you drink alcoholic
beverages? Yes No
Yes No
Yes No
MEDICAL HISTORY
Do you have any dietary restrictions? Yes No
If Yes, explain:
Do you have any medical conditions that may affect your ability to work as a nanny? Yes No
If Yes, explain:
What is your energy level?
Are you physically able to work as a nanny?
Yes No
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Parent category: Business