Care Specialist Application Position you are applying for: select all areas of interest* Child Care / Nanny - live-in Child Care / Nanny - commuter Tutor Senior/Elderly Care Housekeeping Home/Office Organizer Personal Assistant Event Planner Do you have experience in the area of work for which you are applying?* Yes - I have ____ years of experience in the field No - but I have academic background and/or certifications PERSONAL INFORMATIONPERSONAL INFORMATION Name* First Last Birth Date:*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Cell Phone*Provide an alternative phone number: ( ) ________________________________ Contact person: ____________________________________Email* Social Security or ITIN Number*#_______________________________________AVAILABILITY AND SPECIAL SKILLSAvailable Starting Day:*Hours available to work*Days available to work:*Do you have driver's license?* Yes No List State and License Number*Are you certified in First Aid?* Yes No Are you certified in CPR?* Yes No Do you swim ?* Yes - but don't go in deep waters Yes - very confortable in deep waters No Do you have lifesaver certification?* Yes No Are you willing to become certified in these areas?* Yes NO Do you have cooking skills?* Yes - I have cooked for large groups and/or have catering experience Yes - but I only cook for my household No BACKGROUND INFORMATIONHave you ever had a moving or driving related violation or traffic accident (including tickets)* Yes No If yes, list specifics:Have you ever been arrested or convicted of a felony and/or a misdemeanor?* Yes No If yes, please explainHave you ever been the subject of a substantiated complaint of child or sexual abuse?* Yes No If yes, explain FOR LIVE-IN APPLICANTS ONLYThe next question is for live-in applicants onlyHave you ever lived away from home before? Yes No If yes, for how long, and where?MEDICAL - please respond to all questions*Have you done a recent physical exam?* Yes No If yes, when?Please list any medical conditions you have:*Do you have all inmunizations up do date?* Yes No Do you have any diet restrictions?* Yes No If yes, explainDo you take any medication for anxiety or depresion?* Yes No Have you ever been recommended to an alcohol or substance rehabilitation or mental health treatment?* Yes No If yes, when and where?List your allergies, if applicableList any pets you would NOT be comfortable being around:EDUCATIONAL BACKGROUND - Mark the highest educational level completed* High School or GED Certificate Program - specify the type of program Some college credits - specify the area Associates Degree - specify the area Bachelor's Degree - specify the area Other - specify Please add any other type of certifications, special training and/or coursework related to the child care, home care, cooking and/or landscaping industry Please specify the type of certificate / vocational education / college credits or degree you have.Please upload your certificate of completion, diploma, or letters that confirm your credentials.Please upload your resume and other certifications to assist us in the identification of suitable position referrals for you*EMPLOYMENT HISTORYList your last three employment experiences: (start with the most recent)*Location: Position: Phone Number: Supervisor: Length of time you worked at this location: Reason for leaving: List your next employment experience:*Location: Position: Phone Number: Supervisor: Length of time you worked at this location: Reason for leaving: List another experience*Location: Position: Phone Number: Supervisor: Length of time you worked at this location: Reason for leaving: Desired salary range:*List 3 references with phone number and email*Reference #1Reference #2Reference #3 Signature*I certify that I have answered all the questions on this application accurately and to the best of my knowledge. I have not withheld any information which would cause the information given above to be misleading. I understand that any inaccurate or misleading information is grounds for termination of employment.