Names of Adults in Household

Full Name: Full Name :

Primary Email Address: Secondary Email Address:

Residence Address

Street Address: City: Zip Code:

Neighborhood or Area Name:

Home Phone:

Cell Phone
Father: Mother:

Business Phone
Father: Mother:

Company Name or Place of Employment
Father: Mother:

How did you hear about Solutions Home Staffing?

Why type of staff are you seeking?: Nanny Mother's Helper Infant Nanny/New Mother Helper Summer Nanny Short-term Nanny Special Needs Nanny Vacation/Overnight Nanny House Manager Housekeeper Personal Assistant Private Teacher Tutor Pet Sitter House Sitter Home Organizer Specialist Family Cook or Private Chef Elder Companion or Care Handyman

Schedule Needs

Please select the hours that best match your needs: 40 Hours 40 Hours plus Overtime 40 Hours Changing or Atypical Schedule 30-40 Hours Full-Time 20-30 Hours 15-25 Hours Permanent Seasonal or Short-Term Overnight or Live-In Needs

Describe your staff needs, please be as specific as possible:

If hiring a nanny, describe your children, their ages and areas of importance to you about their care:

When do you need to hire this staff member?:

What is the best time and phone number to reach you by phone?:

Any additional information?

According to the application material I have read, the above has been completed accurately to the best of my knowledge.

Your Name:

Your Email:

Date: