NANNIES PLUS  
NANNIES ELITE  
NANNIES PLATINUM  
 (To be determined by Nannies Plus)
Nannies Plus, Inc.
1-800-752-0078
Members of NANC
Please return this completed application with a Recent Photo of yourself
FOR OFFICE USE ONLY
Date Nanny Interviewed
Hired by: Date:
Hired by: Date:
Full Name Today's Date:
Present Address:
City:
State:
Zip:
Present Phone:
Email Address:		 Permanent Address:
City:
State:
Zip:
Permanent Phone:
 
Work# Can we call you at work? If Yes, work hours: Best time to call:
Height (ft. in.): Weight: Date of birth: Age:
PLACEMENT PREFERENCES
Date you could
begin work: 		Salary requested:
Where do you want to be placed?
Anticipated length of stay:
(minimum of
1 year required)		 Will you consider staying
longer than one year?		 Circle Requested Days Off:
Flexible   Sat./Sun   Sun./Mon
Please indicate those family situations in which you would be willing to work (Cirlcle all that apply):
Working mother Working father Single mother Single father Non-working mother Non-working father Mother working
in the home		 Father working in the home
Please circle the ages of children you would like to work with:
Newborn
(0-6 mos)		 Toddler
(1-2 ½ yrs.)		 School age
(6 yrs+)		 Infant
(7 mos - 1 yr.)		 Preschool
(2 ½ yr-5 yrs.)		 All of the above
What is your favorite age group? Maximum #
of children
you would
care for?		 Will your care
for more children,
if one or more are
in school all day?		 Would you care for: Twins? Triplets? ADD or ADHD? Handi-
capped?		 Special
Needs?
If requesting to work with newborns, what experience do you have?
Pets (how do you feel about animals: like, dislike, fear, allergic)
DRIVING (Be Exact. An investigation team will obtain the DMV Report information.)
Do you drive? # of years driving? Drive a stick shift? If yes, for how long? Require use of a car? Bringing your own car? If yes, year/model
Driver's license # Exp. Date: State license is issued:
Any drivers license(s) issued in another state(s) in the last 5 years?
If yes, what state(s)
Do you have any speeding tickets?
If yes, how many and date ticket(s) received
Any other motor vehicle violations?
If yes, explain
Have you been in any car accidents?
If yes, when and did you receive a ticket?
Has your license ever been suspended?
If yes, explain
PERSONAL AND FAMILY BACKGROUND
Father's name Mother's name
Number and ages of brothers and sisters
in your family		 Away from
home for an
extended period
of time?		 List all states you've lived in since age 18 including dates lived there & why:
Do you own any pets? If yes, who will take care of them while you are a nanny?
Are you involved with a boyfriend? If yes, explain (how long dating, where does he live, where will he be when you are a nanny, any marriage plans)
What is Your Religion
Do you need time off to attend religious services? If yes, when? Do you need time off for school? If yes, when?
What are your goals for the future?
At this time are you searching for job opportunities other than being a nanny? If yes, explain
Do you have any allergies? If yes, to what?
Any dietary restrictions? If yes, what?
What are your hobbies and interests?
Do you speak a foreign language? If yes, which one(s)?
Do you swim? YES NO Are you
a good swimmer?		 YES NO Could you work
in a smoking environment?		 YES NO Have you ever been married? YES NO If yes, for how many years?
Are You: divorced widowed separated If yes,
for how
many
years?		 What is your maiden name?
Do you
request
your own
bathroom?		 YES NO Any immediate
family members
in poor health?		 YES NO If yes, explain
Have you ever had a child? YES NO If yes, how many children? What are their ages and where are your children?
Circle the following that describes how well you cook:
Not at all Very limited Can follow through on planned menus Enjoy cooking Full meal preparation Baking and planning meals Gourmet cooking
Would you prefer your employer's home to be: Meticulously neat Very neat Average No preference
INDICATE YOUR INTERESTS BELOW: (Circle only one in each row)
Music: Very much Some-what Not at all   Piano: Very much Some-what Not at all
Computers: Very much Some-what Not at all   Art: Very much Some-what Not at all
Writing: Very much Some-what Not at all   Reading: Very much Some-what Not at all
Sewing: Very much Some-what Not at all   Shopping: Very much Some-what Not at all
Movies: Very much Some-what Not at all   Swimming: Very much Some-what Not at all
Rollerblading: Very much Some-what Not at all   Skiing: Very much Some-what Not at all
Sports: Very much Some-what Not at all   TV: Very much Some-what Not at all

For office use only
H.S. Phone # Date Grad Verified by
College #1 Phone # Date Grad Verified by
College #2 Phone # Date Grad Verified by
EDUCATION
  School, Location & Phone # Yrs Attnd (mm/dd/yy) Date Graduated Degree
HIGH SCHOOL        
COLLEGE        
OTHER        
Major(s) Studied
List any extra-curricular activities in high school and/or college
Are you currently attending college?
Why are you or did you leave college?
EMPLOYMENT Start with you most recent or present job
From To Employer Phone # Job Description Supervisor
           
           
           
           
           
Can we contact your employer? If yes, best time to call?
Please explain any gaps in employment:
Have you ever been employed under any other last name?
If yes, please specify
CHILDCARE EXPERIENCE
Have you been a nanny before?
If yes, how many times?
Are you CPR or First Aid certified?
CHILDCARE EXPERIENCE (Start with present or last position)
From Family or organization
To Address
Length of time/frequency Home telephone #
Ages of children when you began Work telephone #
From Family or organization
To Address
Length of time/frequency Home telephone #
Ages of children when you began Work telephone #
From Family or organization
To Address
Length of time/frequency Home telephone #
Ages of children when you began Work telephone #
From Family or organization
To Address
Length of time/frequency Home telephone #
Ages of children when you began Work telephone #
From Family or organization
To Address
Length of time/frequency Home telephone #
Ages of children when you began Work telephone #
REFERENCES Other references such as daycare experience, nursery, babysitting, camp counselor, teacher's aide, etc.; if possible, 2 teachers or guidance counselors, clergy, NO FRIENDS OR RELATIVES.
Name Relationship To You Phone (home and work)
     
     
     
     
     
Is there any other information that you would like to add that would be helpful in placing you with the right family?
How did you hear about Nannies Plus?
I certify the facts contained in this application are true and complete to the best of my knowledge.
Name/Signature Date
NANNY WRITTEN INTERVIEW
1. What are you doing at present?
2. Why are you leaving this position?

3. Do you think you will get homesick while being a nanny?
If so, how will you handle it?
4. If you are living on your own, how long have you been away from your family?
6. Did you experience any form of neglect or abuse as a child? If yes, please explain
7. What did you like most about your mother/father's parenting skills?
8. What qualities would you look for if you were hiring a nanny?
9. What do you see as your personality strengths?
10. What do you see as your personality weaknesses?
Please answer the following: (you may use this form or elaborate on a separate paper)
1. Describe your personality:
2. Describe your relationship with your family:
3. Tell why you want to become a nanny:
HEALTH INFORMATION FORM
Do you smoke? YES NO If yes, how many per day If requested, could you refrain from smoking in your family's home? YES NO Do you take any frequent medication? YES NO
If yes, please list
Do you have any physical restrictions or impairments or congenital defects? YES NO Are you currently under a physician's care? YES NO Do you consume alcoholic beverages? YES NO
If yes, please explain If yes, why If yes, describe frequency

Any hospital stays?

 YES NO
If yes, when and why
Have you ever been treated for:
Allergies YES NO

Diabetes

 YES NO

Asthma

 YES NO
Heart Disease YES NO

Cancer

 YES NO Leukemia YES NO

Convulsions

 YES NO

Sexually transmitted diseases

 YES NO

AIDS

 YES NO

Other
If you checked YES for any of the above, please explain
If employing family requests, would you submit to:
Physical examination YES NO Drug screening YES NO HIV test YES NO Other YES NO
Are you presently covered by Health Insurance?
If yes, please list insurance company and policy number
In case of emergency, who should be contacted?
Name: Phone # Relationship to you:

Address:

Please check Yes or No to the following questions. Have you ever:
Been convicted of a misdemeanor or felony? YES NO Been on any medication for depression? YES NO Been the driver in a car accident? YES NO

If you checked Yes to any of the above questions, please explain in detail:
I hereby warrant that the facts stated above are true and complete and are made for the purpose of assisting me to secure employment.
Name/Signature Date
*We must have a written release in case any prospective family would like to review this information.
Personal Physician:
Street City State
Zip Phone # Nanny's Name
I hereby authorize you to deliver Nannies Plus, Inc., 520 Speedwell Avenue, Suite 114, Morris Plains, NJ 07950, copies of my medical records and to disclose to them any information that you may have regarding my physical and emotional history and conditions.

Applicants Name/Signature

Date:
AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION
This is to authorize and consent for the release of personal information and acknowledge that American International Security Corporation and others may conduct pre-employment investigations. These investigations might include, but are not limited to, searches of financial or credit agencies, records of previous employment including detailed information on work history, searches of educational institutions, military records, criminal history information on file in local, state or federal agencies, workers compensation records and motor vehicle/driver's license records.
I understand that these searches will be used to determine employment eligibility under the company's employment policies. Therefore, I authorize and consent to full release (either orally or in writing) to the authorized representatives of the company. In addition, I release and discharge the company and its agents and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs, expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that this notice is valid for up to one year from the below date for hiring purposes. After reading this document, I understand fully its complete contents and I authorize the background verification.
In the event that information from the report is utilized in whole or in part in making an adverse decision with regard to my potential employment, before making the adverse decision, I will be provided a copy of the consumer report and a description in writing of my rights under the Federal Fair Credit Report Act.
Print Name:
Signature: Date:
Email Address: Phone #:
Street Address:
City: State: Zip:
Driver's License # State of Issue:
Social Security # Date of Birth:
Please list any previous addresses for the past seven (7) years:
1. 2.
3. 4.
5. 6.

Nannies Plus, Inc.
Office Hours: 10:00 am - 5:00 pm, Eastern Time
P.O. Box 603
Chester, NY 10918, USA
866-492-1039 | Fax 845-468-4404
Contact Form

©1986-2006, Nannies Plus, Inc. Nannies Plus is a trademark of Nannies Plus, Inc.
©1986-2006, Nannies Plus, Inc. All Applications - all rights reserved

INTENT OF REFERRAL
It is our intention to refer you to families in need of live-in childcare. Fees for our services are charged to the families. You receive our service at no charge.

Nannies Plus, Inc. is a referral service. It is your responsibility to negotiate the terms of your employment with the employing families.

If you accept employment with a family referred to you by Nannies Plus, Inc., you are under contract to:

  • Notify us with the name of the family with whom you have accepted employment.
  • Discuss and agree to each of the terms of the enclosed Nanny Work Agreement with your new employer.
  • Agree to begin your position only after Nannies Plus, Inc. receives our placement fee from your employing family.

    Nannies Plus makes every effort to successfully match nannies and families. You should know that our agency guarantees the first 30 days of employment and if for any reason, either you or the family choose to make a change, Nannies Plus, Inc. will provide a replacement nanny to the family without additional charge to the family. At the same time, Nannies Plus, Inc will make every effort to place you with a more suitable family as quickly as possible. Because we have already spent a great deal of time and energy in your particular placement, we would hope that you would permit Nannies Plus, Inc. to place you in your new nanny position.

    In the extremely unlikely event that your performance as a Nanny does not measure up to the standards of Nannies Plus, then Nannies Plus, Inc. is under no legal or contractual obligation to refer you for further employment as a Nanny.

    In addition, you agree to hold Nannies Plus, Inc, harmless for any injuries you may sustain in the course of your employment.

    Please acknowledge your understanding and/or agreement with our terms by signing below and returning this agreement to our office.   (Click Here to Print) Best with Netscape Browser!

    		•
    Signature: Date:
    Please print name here:
    Please mail or fax your completed application as soon as possible with a recent photo of yourself to the address below. Return to Nannies Plus Application Front Page.

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