Domestic Affairs - Exceptional Help For Your Home&Family

DOMESTIC AFFAIRS ONLINE APPLICATION:
Click here to download an application to complete and send via fax
-- or --
Please fill out all of the following information:

Today's Date:
Name:
Date of Birth:
Address:
City, State, Zip:
Home Phone:
Cell/Pager:
Email Address:
Emergency Contact Name
Emergency Contact Telephone
Emergency Contact Relationship to you
How long have you lived in Los Angeles?
Where did you live previously?
Country of origin:
Elegibility to work in the U.S. (Check One) :
Citizen.: Green Card: Work Permit: Employment Authorization:

Do you drive? Yes No		Do you have car insurance? Yes No
Name of Auto Insurance Co.:
Driver's License No.:
Driver's License State:
Do you own a car?		Yes No
What Year and Model:
Are you able to use your car on the job?	Yes No
Do you need to have a car provided?	Yes No

YOUR SKILLS
HOUSEKEEPING (Please check all that apply): Light Housekeeping Duties Full Housekeeping Duties Kitchen (dishes, floors, appliances) Bathrooms Bedrooms (change linens) Laundry for the children Laundry for the family Ironing Have you worked in a large home? Have you worked in a staffed home? Are you willing to wear a uniform, if the job requires one?
COOKING (Please check all that apply): For children only Simple meals for the family Able to follow recipes Gourmet Know how to set a proper table Formal Service Attend Cooking School? Name of Cooking School:
CHILDCARE What ages of children have you taken care of?
Do you have special skills, experience, or qualifications related to the position?
What activities do you enjoy doing with that age group?

Have you had CPR training?	Yes No
Do you know how to swim?	Yes No
Are you available to travel with family?	Yes No
Occasionally?	Yes No
Internationally?	Yes No
Do you have any hobbies or interests?
Do you read books to the children?	Yes No
What other languages do you speak?

EMPLOYMENT DESIRED (Please check all that apply):
Live-in Live-out Full Time Part Time Weekends
Shift or Hours Available:
Date you can start:
Salary Range:

EDUCATION:
In what country did you attend school?
How many years of school did you complete?
Did you graduate High School?	Yes No
Did you attend College, University, or Trade School?	Yes No
Name of school:
Are you currently enrolled in school? :	Yes No

HEALTH:
General health:	Excellent Good Fair
Do you have any physical limitations? Please explain: Do you have any food allergies?
Are you allergic to cats or dogs?	Yes No
Have you had a TB Test?	Yes No
Date of last Dr.'s visit:

EMPLOYMENT HISTORY: Please list your most recent Employer first. Employment #1:

Employer name:
Employer address:
Employer City, State
Employer phone:
Start Date:		End Date:
Reason for leaving:
Childcare:
Number of children:
Ages of children when you left:
Check your duties (Please check all that apply): Housekeeping Cooking Childcare Errands
Describe your duties:

Employment #2:
Employer name:
Employer address:
Employer City, State
Employer phone:
Start Date:		End Date:
Reason for leaving:
Childcare:
Number of children:
Ages of children when you left:
Check your duties (Please check all that apply): Housekeeping Cooking Childcare Errands
Describe your duties:

Employment #3:
Employer name:
Employer address:
Employer City, State
Employer phone:
Start Date:		End Date:
Reason for leaving:
Childcare:
Number of children:
Ages of children when you left:
Check your duties (Please check all that apply): Housekeeping Cooking Childcare Errands
Describe your duties:

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. I swear that the submitted information is true and correct.

Authorize Yes Authorize No

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