Place a Job Order

Date:

Referred by:

Name:

Spouse:
   Spelling verified?

Street Address:

City:

State/Province:

Zip/Postal Code:

Home Phone:

Work Phone - Ms:

Work Phone - Mr:

Cell Phone:

Email:

Fax:

CHILD #1
Name:    
Age:
School:
Special Needs:

CHILD #2
Name:   
 Age:
School:
Special Needs:

CHILD #3
Name:    
Age:
School:
Special Needs:

CHILD #4
Name:    
Age:
School:
Special Needs:

Live-in    Live-out
Days:    Hours:

Car Needed?    yes    no

Car Provided?    yes    no
     for work?    off time?   Type of car:

Cook for adults?    yes    no

Adults' Laundry?    yes    no

Swim?    yes    no

Does anyone Smoke?    yes    no

Responsibilities:
Child's room    Kitchen    Vacuum    Pets   

Other responsibilities:

Salary per week

Domestic travel needed?    International travel needed?
How often:

Living arrangements for live-in jobs:
Private room?    Bath?    Phone?

Start date of job

Begin interviewing

Previous history with domestic help

Miscellaneous