Joanna Gray Agency
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Call us at 770-569-0444

Candidate Application Form

Personal Information

First name:   M.I.: Last name: 
Address:
City: State:
Zip: Apt./Unit #:
Home phone: E-mail:
Work phone: Cell #:
Available
Start Date:		 Position applied for:
Desired Salary: $ Emergency Contact(s):
Birth date:(optional) Name and Address:
Marital status: (optional)  
Do you have children? If yes, names & ages:  
Are you a citizen of the United States? Yes No
If no, are you authorized to work in the U.S.? Yes No N/A
Have you ever been convicted of a felony? Yes No
If yes, explain:
Do you drive? Yes No
If yes, year and make/model of automobile:
Do you have anything on your driving record for the past 7 years?:

Skills: (Select all that you are willing to do)

Cleaning:

 Yes No

Floors:

 Yes No

Laundry:

 Yes No

Ironing:

 Yes No

Cooking:

 Yes No

Childcare:

 Yes No

Errands:

 Yes No

Grocery Shopping:

 Yes No

Childcare Skills

Do you have favorite ages of children?
How many children are you comfortable caring for?
Are you willing to do carpooling? Yes No
Do you swim? Yes No
Are you CPR and First-Aid certified? Yes No
Do you like pets? Yes No

How did you hear about Joanna Gray Agency?

Personal Reference
Yellow Pages Yes No
Web Search? Yes No
Which Search-Engine?
Which Phrase?
Are you registered with another agency? Yes No

Health Information

Do you smoke? Yes No
Have you had a physical exam in the past year? Yes No
Do you have any allergic conditions (such as cats or dogs that we need to be aware of)? Yes No
If Yes, please explain
Do you have any physical conditions that will affect your job performance? Yes No

Education

High School

Name: Address:
From: Did you graduate: Yes No
To: Degree:

College

Name: Address:
From: Did you graduate: Yes No
To: Degree:
Major: Minor:

Other

Name: Address:
From: Did you graduate: Yes No
To: Degree:
Major: Minor:

Previous Employment

Please do not leave gaps in employment history.
Company: Phone:
Address: Supervisor:
Job Title: Email Address:
Responsibilities Reason for leaving:
From:  
To:  
May we contact? Yes No
Company: Phone:
Address: Supervisor:
Job Title: Email Address:
Responsibilities Reason for leaving:
From:  
To:  
May we contact? Yes No
Company: Phone:
Address: Supervisor:
Job Title: Email Address:
Responsibilities Reason for leaving:
From:  
To:  
May we contact? Yes No

Childcare/Domestic References

Please list three references. Do not list family or friends.
Full Name: Relationship:
Company: Phone:
Ages of children cared for: E-mail:
Reason for Leaving:  
Full Name: Relationship:
Company: Phone:
Ages of children cared for: E-mail:
Reason for Leaving:  
Full Name: Relationship:
Company: Phone:
Ages of children cared for: E-mail:
Reason for Leaving:  

Please describe why you are seeking a childcare/domestic position at this time.

All answers provided both in this application and given during any interview are true, correct and complete, and that I have not omitted any information. If any answer is found to be false or misleading, any employment will be immediately terminated.