Application Form to be a Nanny/Mothers Help/Maternity Nurse/Other

Ref. No Date
Post Required Start Date
Name Address including Post Code
Telephone No. Religion
Age & Date of Birth* *If under 18 years, have you had any careers guidance?  
Fathers' Occupation Mothers' Occupation
Ages of Brothers (if any) Ages of Sisters (if any)
EXPERIENCE (Please tick age groups)
Newborn 3mths - 1yr  1yr - 3yrs            3yrs - 5yrs     5yrs -7yrs+ 
SKILLS (please tick)  Can you Swim    Cook                Drive      
Do you hold a full license?      Do you own a car?           Make & Model 
Have you done any first aid?      If yes, what qualifications
Other skills   
OTHER INFORMATION:  Do you Smoke           Are you prepared not to smoke in the home  
Speak a Foreign Language     Suffer from homesickness        
Any Criminal convictions         Do you have Police Certificate
Are you prepared to work anywhere       If 'No' where are you prepared to work   
Daily              Residential          Special diet     Will you do light housework
Will you work in a family where there are pets  Are you willing to work with a single parent
What salary do you expect?  
What are your hobbies and interests?  
Are you physically fit ? Is your Health Good ? Height Weight
Do you have any psychiatric or
 disability problems  		Please give details of treatments
 
EDUCATION Start date Finish Date Qualifications
Last School
College
EMPLOYMENT HISTORY
Name & Address of Employer Position & age of Children Start Date Finish
 Date
 		Reason for leaving Nett Salary

For Immediate Instructions to Families we need Two References
My referees will write directly to the agency 
Referees - State whether friend, employer, college tutor etc.
Name         Name
Address     Address
Telephone  Telephone

1. All interviews shall be arranged by the Agency and no arrangements may be made between potential employees and the clients unless authorised by the agency.
2. After an introduction, the Agency must be informed of all further developments.
3. Introduction of clients is confidential and must not be passed to any third parties.
4. The Agency does not insure workers against accident, or possible claims against third parties. Persons put forward by the agency are solely responsible for their own acts or omissions.

NB You are not employed by this Agency. You are employed directly by the people for whom you work.

I declare that to the best of my knowledge the details given above are true and that I have read and agree to abide by the above conditions and rules of the Agency.

Signed      Date 


      For a printed copy click on your browser's Print button before pressing Send Form.