Permanent Nanny Application Fill out the online form below and press send. Alternatively, you can print out the PDF version and email or fax it to us. Name* First Last Email* Date of Birth* Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home PhoneSSN*Driver's License NumberInsurance CompanyEducationHighest Level of Education CompletedChildcare CoursesList courses you have taken that are relevant to the childcare field, ex: child development, psychology, nutrition, health, infant/child CPR, first aid, family relations, etcExperienceIn order to determine family/nanny compatibility, please check all statements that are relevant to you and provide accurate information where appropriate:I have worked with infants Yes Describe work with infants:I have worked with toddlers Yes Describe work with toddlers:I have worked with children in preschool: Yes Describe work with preschoolers:I have housekeeping experience: Yes Describe housekeeping experience:I have cooking experience: Yes Describe cooking experience:I have worked with children with allergies: Yes Describe work with children with allergies:I have worked with children with special needs: Yes Describe work with children with special needs:I have administered medications to children: Yes Describe work with administering medications:I have traveled with children: Yes Describe experience traveling with children:I have watched children and houses while parents traveled: Yes Describe experience watching children and homes:I have gotten driving tickets: Yes Describe your traffic violations:Personality and Health I smoke I dislike cats I dislike dogs I prefer to spend my free time...AloneWith othersMy health is...*ExcellentGoodFairPoorHealth explanationDo you have any allergies?YesNoList allergens hereDo you take any medications on a daily basis?YesNoList medications hereAvailability and CompensationDate available for referrals Days of week available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Times available on Monday:Times available on Tuesday:Times available on Wednesday:Times available on Thursday:Times available on Friday:Times available on Saturday:Times available on Sunday:What kind of work are you seeking? Check all that apply. Full-Time Part-Time Live-In Live-Out Local Out of State How far will you drive for a job?Minimum hourly pay requiredMinimum monthly pay requiredResponsibilitiesCheck additional responsibilities you are willing to perform: Cooking Shopping Light Housekeeping Heavy Housekeeping If you are seeking a position out of state, please explain how you will adjust to the area, and how you will develop a support system of friends.Describe in detail things you are looking for in a family.(number of children, ages of children, life style – formal vs informal, religion, benefits seeking – car insurance, health insurance, vacation, etc., preferred location of the family …and anything else you think is important.)Background CheckI agree to provide NW Nannies LLC with a police background check for every state in which I have lived since age 18. Yes States Lived InPlease list all of the states you've lived in and the dates you lived in each.Work ExperienceList all work experiences, starting with your most recent employment, in the past ten years. Include part time employment.Employer & PositionSupervisorAddressPhoneDates EmployedResponsibilitiesEmployer & PositionSupervisorAddressPhoneDates EmployedResponsibilitiesEmployer & PositionSupervisorAddressPhoneDates EmployedResponsibilitiesEmployer & PositionSupervisorAddressPhoneDates EmployedResponsibilitiesEmployer & PositionSupervisorAddressPhoneDates EmployedResponsibilitiesReferencesList FIVE references, three of which are childcare related, one of which must be within the last six months. None may be a relative. Please provide telephone numbers at which we can reach the references during the day.Reference #1 Name First Last PhoneAddressHow long have you known this person?How do you know this person?Reference #2 Name First Last PhoneAddressHow long have you known this person?How do you know this person?Reference #3 Name First Last PhoneAddressHow long have you known this person?How do you know this person?Reference #4 Name First Last PhoneAddressHow long have you known this person?How do you know this person?Reference #5 Name First Last PhoneAddressHow long have you known this person?How do you know this person? NW Nannies LLC affirms the right of all individuals to equal opportunity in referrals for employment without regard to race, color religion, national origin, sex, age, marital status or any other extraneous considerations not directly or substantially related to effective performance. Upon being hired by a family referred through NW Nannies LLC, I agree to participate in a drug screening test, at no cost to me. By pressing "Send", I certify that the information given herein is true and complete to the best of my knowledge. This iframe contains the logic required to handle Ajax powered Gravity Forms.