Type of Position/Placement:

Type of Services

—Please choose an option—Child Care ServicesSenior Care ServicesHousehold Management

Job Duties/Responsibilities:– Please Describe

Long term placement?

Short term placement?

Employee Payroll Services Required:

Would the employee Live-In

If Yes, Will the Employee have a separate bedroom

Additional Requirement & Home Information:

Start Date

Completion Date

Wage($)

Hours per week

Days Off

Overtime hours

Evenings Required?

Holidays Required?

Weekends Required?

Driver's License Required?

If yes, will car be provided?

Does any one smoke in your home?

Any health problem with any one in your family?

If yes, list

List pets, if any

Have you previous hired a Nanny/Caregiver or Household staff?

If yes, why is your employee leaving?

Please list any special skills required:(i.e. swimming etc)

What qualities about your employee are most important to you?

Please indicate which security clearance you would required from the employee?

Additional requirements:

Select Placement Fee Package

—Please choose an option—Priority - 90-Day Replacement PolicyPreferred - 180-Day Replacement PolicyPremier - 365-Day Replacement PolicyOne Month Temporary PlacementTwo Months Temporary PlacementPart-Time PlacementImmigration ServicesOthers