• * Required

  • Personal Information

    Please provide your full legal name.
  • Format: +0000000[0][0][0][0][0][0][0][0].
  • Format: +0000000[0][0][0][0][0][0][0][0].
  • Format: +0000000[0][0][0][0][0][0][0][0].
  • May we phone you at work?
  • Do you smoke?*
  • Will you work in a household, where there is a smoker?
  • Available Start Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Which employment arrangements would you consider? Select all that apply.*
  • Which rotational (ROTA) schedules would you consider?*
  • Would you consider a fly-in/fly-out arrangement for a rotational assignment?*
  • Which family travel would you consider?*
  • What is your current passport status?*
  • Do you have a driver's license?*
  • Do you own a reliable car?*

  • If offered a position by one of our clients, will you submit to:

  • Mandatory drug screening?*
  • Fingerprinting?*
  • Physical examination?*
  • Have you EVER been convicted of a felony and/or misdemeanor?*
  • Are you legally authorized to work in the United States?*

  • Educational Background

  • Do you have a high school diploma?*
  • GED?
  • Which professional childcare specialties do you have experience in? Select all that apply; leave blank if none.
  • What is your current CPR and First Aid certification status?*
  • When does your current CPR certification expire?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • When does your current First Aid certification expire?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Which age groups have you cared for professionally? Select all that apply; leave blank if none.
  • Can you swim?*

  • Vehicle use and live-in experience

  • Will you drive your vehicle to work?
  • Have you ever been a live-in employee?

  • Employment History

  • Current or Most Recent Employer

  • Format: +0000000[0][0][0][0][0][0][0][0].
  • Hiring Date:*
     - -
  • Ending Date:
     - -
  • Can we contact this employer for a reference?*

  • Previous Employer

  • Format: +0000000[0][0][0][0][0][0][0][0].
  • Hiring Date:
     - -
  • Ending Date:
     - -
  • Can we contact this employer for a reference?
    • Add More Previous Employer 

    • Previous Employer

    • Format: +0000000[0][0][0][0][0][0][0][0].
    • Hiring Date:
       - -
    • Ending Date:
       - -
    • Can we contact this employer for a reference?
    • Add More Previous Employer 

    • Previous Employer

    • Format: +0000000[0][0][0][0][0][0][0][0].
    • Hiring Date:
       - -
    • Ending Date:
       - -
    • Can we contact this employer for a reference?

  • Previous Name(s) Known By

  • Please check all tasks you are willing to accept

  • Additional personal-care tasks you would consider:
  • Domestic Tasks:
  • Do you know any foreign language(s)?*
  • Do you have any pet allergies we should be aware of?*

  • DDA Applicant Agreement

  • Deb's Domestic Agency is acting as a referral agent to select and refer jobs for you to consider as a domestic employee in someone’s home. You are under no obligation to accept a referral to a job offer from anyone we refer to you. All agreements regarding your job are between you and your employer. By putting check marks on all 11 statements below, signing at the end of this application, and accepting employment referrals from us, you agree to the terms & conditions for working with our agency.

  • Please upload your current résumé using the résumé-upload field in this application. Do not email Social Security cards, birth certificates, passports, driver’s licenses, work-authorization documents, proof of insurance, or other sensitive identity records. If additional documentation is genuinely needed later in the placement process, Deb’s Domestic Agency will contact you and provide a confirmed secure upload link. Do not send sensitive documents unless DDA specifically requests them through that secure process.

  • Authorization and Release to Obtain Full Background Report Information

  • I, the undersigned party, have applied for employment with Deb's Domestic Agency. I hereby authorize Deb's Domestic Agency and/or its authorized agent, BackgroundPartner.com to conduct a pre-employment screening of my personal background. The background research may include any of the following: Nationwide, State or Local Criminal History, Motor Vehicle Record (Driving History), Drug Testing, Verification Regarding My Character, General Reputation, Personal Characteristics, and Mode of Living. I understand and agree that this background research will be conducted prior to my employment position begins. I further agree that, at the discretion of Deb's Domestic Agency this release allows for additional searches of my personal background at anytime during my employment, as allowed by state and federal law. I hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as from any liability that might otherwise result from the request for. use of and/or disclosure of any or all of the foregoing information. I agree that a copy or facsimile of this authorization has the same effect as an original.

    The legal name, date of birth, and current address supplied in Personal Information apply to this authorization. My signature at the end acknowledges the Applicant Agreement and this authorization.

  • Social Security Number

  • Sex:
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  • Photo

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  • To sign:

    From a cell phone: Use your finger on your cell phone screen
    From a laptop: Use your finger on your trackpad
    From a desktop: Use your mouse

  • Signature*
  • Should be Empty: