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First Name:
Last Name:
Home Address:
State: Zip:
Home Phone:
Home Fax:
Business Address:
Business City:
Business State: Business Zip:
Business Phone:
Business Fax:
Parent 2 First Name:
Parent 2 Last Name:
Parent 2 Occupation:
Parent 2 E-mail:
Parent 2 Home Address:
Parent 2 City:
State: Zip:
Parent 2 Home Phone:
Parent 2 Home Fax:
Parent 2 Business Address:
Parent 2 Business City:
Parent 2 Business State: Business Zip:
Parent 2 Business Phone:
Parent 2 Business Fax:
Proposed Salary:

Select how you would like to receive our Agency Agreement and Waiver of Liability form:
If you have selected fax, please enter your fax number:

When do you need your Nanny to start?

Please list the children in your home:

Name Age Sex Birth Date Hours in School

Are you seeking a live in or live out help? Live In Live Out

If live in, please describe accommodations.

Caregiver's work schedule (Please note that American Nanny Company, Inc. requires two days off):

Do you require driving? Yes No

If yes, what kind of vehicle?

How Accessible is your home to public transportation?
Very Accessible
Moderate Accessibility
Poor Accessibility

What qualities do you look for in a Nanny?

What are the Nannies responsibilities?

Will you provide health insurance for Nanny? Yes No

Will the Nanny receive a pay bonus? Yes No

What will the Nanny's salary be?

Will the Nanny be required to travel?

Will the Nanny have club benefits?

Will the Nanny have access to vehicle for personal use? Yes No

Will the Nanny have access to personal T.V.? Yes No

Will the Nanny have access to personal phone? Yes No

Will the Nanny be reimbursed for any tuition? Yes No

Do you have household pets? Dog Cat

Do you require a non-smoker? Yes No

How did you find American Nanny Company?

Please feel free to add any additional supportive information about your family or any other special requests or needs you might have to assist in the placement process. Also, if you found a nanny in our "on-line nannies available" section, please list.

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