May 18, 2018form testUncategorized Job Application Personal InformationThe other sections of this application will expand or collapse when you click the arrow. Please expand each section and fill it out before you click the submit button. If you leave a required field blank, the system will take you to that field for completion. Required fields are flagged with a RED asterisk. Name * First Middle Middle Last * Last Address * Address Line 2 (Apt # or Building) City * State * ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Postal Code * Country * AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte d'IvoireCroatia (Hrvatska)CubaCyprusCzech RepublicCongo (DRC)DenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Islas Malvinas)Faroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong Kong SARHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SARMacedonia, Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe Email * Alternate Email Work Phone Home Phone * Mobile Phone Employment Desired * Full-time Part-time Full- or Part- time Available Start Date * Position Applied For NannyHousekeeperBaby NurseHouse ManagerButlerChefLaundress Attach Resume Drop a file here or click to uploadChoose FileMaximum file size: 516MB Desired Salary Birthdate (Optional) Marital Status (Optional) Do You Have children? If yes, names and ages Emergency Contacts Are You a US Citizen? Yes No If no, are you authorized to work in the United States? Yes No Have You Ever Been Convicted of a Felony Yes No If yes, please explain. Do You Drive? Yes No If yes, list make and model Do you have anything on your driving record for the past 7 years? End of Personal Section Skill Section arrowup6 Cleaning Yes No Floors Yes No Laundry Yes No Ironing Yes No Cooking Yes No Child Care Yes No Errands Yes No Grocery Shopping Yes No End of Skills Section Child Care Skills arrowup6 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 Search phrase? Are you registered with another Agency? Yes No Ages of children cared for End of Child Care Section Health Information arrowup6 Do You smoke? 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 Have you had a physical examination in the past year? Yes No Do you have any physical conditions that will affect your job performance? Yes No If yes, please explain. End of Health Information Education Section arrowup6 High School High School Address Years attended Did you graduate Yes No Degree College Name College Address Years attended Did you graduate? Yes No Major(s) Minor(s) Other Education Address Years attended Did you graduate? Yes No Degree Yes No Major(s) Minor(s) End of Education Section Previous Employment arrowup6 Company Address Phone Supervisor Job Title Email Address Responsibilities From To Reason for Leaving May we contact? Yes No End of First Company Second Company Address Phone Supervisor Job Title Email Address Responsibilities From To Reason for Leaving May we contact? Yes No End of Second Company Company 3 Address Phone Supervisor Job Title Email Address Responsibilities From To Reason for Leaving May we contact? Yes No End of Previous Employment First Reference arrowup6 Childcare/Domestic References Please list three references. Do not list family or friends. Full Name Relationship Company Phone Ages of children cared for Email address Reason for Leaving End of First Reference Second Reference arrowup6 Full Name (Second Reference) Relationship Phone Ages of children cared for Email Reason for Leaving Company End of Second Reference Third Reference arrowup6 Full Name (third reference) Relationship Phone Company Email address Ages of Children Cared For Reason for Leaving End of Third Reference AgreementAll 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. Enter your email address to agree * Subject Your Message Please describe why you are seeking a childcare/domestic position at this time I understand that I am now under agreement with Joanna Gray Agency, Inc. and are obligated to report to ALL phone calls, interviews and jobs that I have been offered by any of the agency's clients, or its client's friends, neighbors, relatives and associates. This includes all people I have met who I would not have met if I were not affiliated with the agency.* Yes I agree not to be employed by any of these people unless I have obtained authorization to do so from the agency directly.* Yes I understand that the above mentioned people must pay the appropriate fee to the agency in order to employ me and that it is my responsibility to check with the agency to make sure that the fee has been paid.* Yes I agree not to refer my friends, relatives and/or affiliates to the above mentioned (agency clients, friends and family) associates, for employment purposes.* Yes I agree to pay the agency $10,000 and any legal fee's incurred by the agency if I violate the terms of this agreement.* Yes I declare that all the statements and answers in this application are true and complete and agree that any untrue or misleading answer, omission, concealment or failure to answer any questions fully, completely and accurately may be grounds for terminating my employment, regardless of when it is discovered. By completing this application, I give this employer permission to validate some of my answers with the appropriate authorities/institutions.* Yes I authorize this employer or its agents to investigate my references, to review my former employment record and to keep and preserve records of such investigations. Additionally, I release all parties from liability for any damage that may result from furnishing information to this employer or its agents.* Yes Print Name (Signature) : * Date Signed: I have been verbally instructed and I agree to the terms of this employment contract. * YesNo Initial: * Date Copyright © 2025 | Joanna Gray Agency, Inc. All Rights Reserved. Atlanta | 404-933-1753 https://www.joannagrayagency.com Captcha If you are human, leave this field blank.
