Employment Application Form

Employment Application

Fill the form below accurately indicating your potentials and suitability to job applying for.
Name*

First NameLast Name
Birth Date

MonthDayYear
Phone Number*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What position are you interested in?

Full Time NannyPart Time NannyLive In NannyFamily AssistantPersonal ChefHouse ManagerEstate ManagerHousekeeper
Available Start Date:

MonthDayYear
Date
Preferred Weekly Hours:
Are you applying for a specific Job #?
Do you have a valid driver’s license?

YesNO
Are you legally authorized to work in the United States?

yesno
Do you have reliable transportation?

Yes I have a carI do not have a car
Are you willing to relocate for the right position?
Preferred work locations or regions:
Do you hold (or are you willing to obtain) a valid passport for travel positions?

yesno
Hourly or Salary Range Desired:
Experience & Qualifications
Years of Professional Experience in Domestic Roles post 18
List Prior Relevant Experience
Do you have experience caring for children of these ages?

Infant (0–12 months)Toddler (1–3 years)Preschool (3–5 years)School-age (5–12 yearsTeenagers
Do you have experience with the following household duties?

Meal prep / cookingLaundry / ironingHouse management / schedulingDriving childrenPet careElderly careHousekeeping / organizing
Certifications: CPR / First Aid, TrustLine / Fingerprinting, Special Needs Care Etc.
Resume and Files

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References

Please list two (2) references that are familiar with your work life.
Reference
Reference
Professional Preferences
Preferred Household Type

Formal / Fully StaffedInformal / Casual Family EnvironmentEither
Comfortable Working With:

Children with special needsHigh-profile familiesPetsMultiple staff membersWork-from-home parents
Are you open to occasional travel or overnights?

YesNo
Are you willing to undergo a background check, including motor vehicle and drug screening?

yesno
Are you willing to sign a confidentiality / NDA agreement?

YesNo
Are you comfortable with homes that have cameras:

yesno
Tell us about yourself and what type of household you thrive in:
Upload a Recent Photo for your profile:

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Acknowledgment
By submitting this application, I acknowledge and agree that:Balia Referral Agency LLC DBA Balia Household Staffing is a referral and placement agency and does not employ household staff directly.This application does not guarantee placement or employment.I authorize Balia Household Staffing to contact my references and, if applicable, conduct standard background, drug, and motor vehicle checks as part of the placement process.I certify that all information provided in this application is true and complete to the best of my knowledge.☐ I agree to the above terms and certify that the information provided is accurate.

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How were you referred to us?*

Walk-InReferralNewspaper AdFacebookTwitterLinkedInOther (please specify)
Should be Empty:

Employment Application

Experience & Qualifications

Professional Preferences

Acknowledgment