* First Name:
* Middle Initial:
* Last Name:
* Address Line 1:
Address Line 2:
* State:
* Zip Code:
Home Phone:
Cell Phone:
Work or Emergency Phone:
* Email Address:
* How soon can you start a new job?
* Seclect choice of jobs (If more than one, click on "OTHER", and list all types of jobs you seek) NOTE: You may only apply for jobs that you have actually performed, and for which verifiable references are available:
If 'Other' Please Specify:
* Select Choice:
* Select Choice:
If you clicked "Part-Time" or "Ok Both" list the days and hours you can work:
* Marital Status:
If you have children, list ages and sex. If no children write none:
* Languages Spoken:
Drivers License Need At Time Of Interview Social Security Number Need At Time Of Interview
* Date of Birth (For Background Check):
* Country of Origin:
* How Long in the USA?
* How Long in the Los Angeles?
* Cooking Ability:
If "Other" please specify:
* Housekeeping Ability:
If "Other" please specify:
* Laundry Ability:
If "Other" please specify:
* Ironing Ability:
If "Other" please specify:
* Driving Ability:
If "Other" please specify:
How long have you been driving?
Do you have your own car?
If you have your own car please specify the Year, Make and Model:
* Childcare Ability:
If "Other" please specify:
List Preferred children's ages you wish to work with:
Education (State the highest level reached, plus your major and minor subjects):
List below any additional expertise, special courses, certificates, diplomas, talents, sports
Do you smoke?
If "Other" please specify:
Will you take a job outside of California?
If "Other" please specify:
Can you travel outside of the U.S. for short trips?
If "Other" please specify:
Do you take any medication that could impair your judgment or reflexes?
If "Other" please specify:
Would you be willing to take a drug test?
If "Other" please specify:
Do you have any serious health problems?
If "Other" please specify:
Do you have any physical impairments that may limit your work capacity?
If "Other" please specify:
Can you swim?
If "Other" please specify:
Do you like pets?
If "Other" please specify:
Have you ever been convicted of a crime?
If "Other" please specify:
If you said yes, please explain:
Have you ever been arrested for a felony or misdemeanor?
If "Other" please specify:
If you said yes, please explain:
Are you aware that the agency may conduct a criminal background check prior to placing you?
If "Other" please specify:
Are you certified for CPR?
If "Other" please specify:
Do you certify that all of the information in this form is true and correct?
Previous Employment
Previous Job 1
Name(s) of Employer(s)
First Name:
Last Name:
Suffix:
First Name:
Last Name:
Suffix:
Employer(s) Profession(s):
Address:
City:
State:
Zip Code:
Phone numbers to call for references:
Did they give you a letter of reference?
Was this a:
Was this job full-time or part-time?
Email (Not a requirement but helpful):
Start date and ending date (If still employed, write "Still There")
Job Title
List your duties (If you cared for children, write all their ages when the job started)
Reason for leaving the job. Also write the ending salary
Previous Job 2
Name(s) of Employer(s)
First Name:
Last Name:
Suffix:
First Name:
Last Name:
Suffix:
Employer(s) Profession(s):
Address:
City:
State:
Zip Code:
Phone numbers to call for references:
Did they give you a letter of reference?
Was this a:
Was this job full-time or part-time?
Email (Not a requirement but helpful):
Start date and ending date (If still employed, write "Still There")
Job Title
List your duties (If you cared for children, write all their ages when the job started)
Reason for leaving the job. Also write the ending salary
Previous Job 3
Name(s) of Employer(s)
First Name:
Last Name:
Suffix:
First Name:
Last Name:
Suffix:
Employer(s) Profession(s):
Address:
City:
State:
Zip Code:
Phone numbers to call for references:
Did they give you a letter of reference?
Was this a:
Was this job full-time or part-time?
Email (Not a requirement but helpful):
Start date and ending date (If still employed, write "Still There")
Job Title
List your duties (If you cared for children, write all their ages when the job started)
Reason for leaving the job. Also write the ending salary
* Security Code:
