Call us at 770-569-0444

Client Application Form

Client

Name:
Address:
City:
State:
Zip:
Home Phone:
Fax:
Employer/Occupation:
Work Phone:
Work Fax:
Cell Phone:
Email Address:

Spouse's Name:
Employer/Occupation:
Work Phone:
Work Fax:
Cell Phone:
Email Address:

How were you referred to Joanna Gray Agency?
What other means of acquiring help are you investigating?

Children

Name:	Age:	School Schedule:	Special Needs or Concerns:




Does your child or children have any special needs? Yes No
If Yes, please explain:

Positions Required (Check all that apply):

Nanny

Baby Nurse

Governess

Personal Assistant

Chauffeur

  Housekeeper
  House Manager
  Houseman
  Chef

  Estate Manager
  Couple
  Butler
  Laundress

Services Required (Please check all that apply):

  Childcare Only
  Infant Care Only
  Childcare / Housekeeping
  Carpooling
  Grocery Shopping
  Errands

  Laundry (Family)
  Laundry (Children’s)
  Housekeeping Only
  Ironing

Plant Care
Pet Care

  Basic Cooking
  Elder Care
  Driving/Carpooling
  Other

Skills Required (Please check all that apply):

  Does employee need their own car?
  Ability to assist with homework?
  Formal training for position?
  Second language preference?
If so, which one?

Household Information

Is the atmosphere of your home formal, semiformal, or casual?
What is the approximate square footage of your home?
Number of levels?
Number of rooms?
Number of bedrooms?
Number of bathrooms?
Do you have any pets?	Yes No
If so, give a brief description.
Will employee be responsible for pet care?	Yes No
If yes, describe care required.
Is there a second language in your home?	Yes No
If yes, please explain.
Does you house have a pool?	Yes No
Does anyone in your home smoke?	Yes No

Compensation (Please check all that apply) :

Salary: Pay range (gross wages/week)

$300-$350 $350-$450 $450-$650 $650 - $850 Other

Days required to work:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Hours:

Benefits Package (Please check all proposed benefits that apply):

	Paid legal holidays after months of employement? (Most holidays include: New Years Day, MLK Jr. Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Hanikkakh and/or Christmas Day)
	Paid sick days after months of employment.
	Paid vacation days after months or year of employment.
	Overtime pay for working over hours per week.
	Guaranteed salary if the employee is not needed.
	Annual salary review and/or bonus.
	Health Insurance
	Dental Insurance
	Automobile Insurance
	Retirement Plan
	Mileage Reimbursement per mile.

For live-in employees, please check the following provided accommodations.

Private bedroom Private bathroom Furnished Television Private phone line Private entrance Allow visitors when off duty? Employee may stay or leave when off duty?
Where are the living quarters located?

Employer/Employee Relationship (Please check all that apply)

What qualities are you looking for in your employee?	Outgoing Reserved Take charge Sense of humor Non-smoker Other
What type of relationship would you like to have with your employee?	Employer/Employee relationship Member of the family Friend Depends on person
Do you prefer that your employee wear a uniform?	Yes No
Will you provide them with uniforms?	Yes No
We would prefer our employee to address us by our	First Name Family Name
We would prefer our employee to answer the phone in the following manner: