The Rossi Agency

The Rossi Agency

Position applying for: ______Date: ______

Personal Information

Name: ______Date of Birth: ______

Any past legal names: ______Social Security: ______

Current address: ______

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Phone: ______Alternate Phone: ______

Are you a U.S. citizen? ______

If no, describe your legal status: ______

A candidate is any person who is seeking a placement for domestic help through The Rossi Agency. The Rossi Agency will conduct screening and initial interviews to determine eligibility for placement as domestic help. It is up to each family as to who they hire based on their needs for experience, education and scheduling.

I am submitting my application to become a candidate through The Rossi Agency. ______

I understand that I must consent to a full background check to be eligible to be a candidate. ______

I understand that I must consent to a credit check to be eligible to be a candidate. ______

I understand that I must consent to a drug screening to be eligible to be a candidate. ______

I understand that any misrepresentation in the application process will terminate my status as a candidate for placement through The Rossi Agency. ______

Employment History (Most recent first)

Position/Title: ______Employment Dates: ______

Company/Family: ______

Address: ______

Supervisor: ______Phone: ______

Email: ______

Describe your responsibilities: ______

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Reason for leaving: ______

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Position/Title: ______Employment Dates: ______

Company/Family: ______

Address: ______

Supervisor: ______Phone: ______

Email: ______

Describe your responsibilities: ______

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Reason for leaving: ______

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Position/Title: ______Employment Dates: ______

Company/Family: ______

Address: ______

Supervisor: ______Phone: ______

Email: ______

Describe your responsibilities: ______

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Reason for leaving: ______

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Position/Title: ______Employment Dates: ______

Company/Family: ______

Address: ______

Supervisor: ______Phone: ______

Email: ______

Describe your responsibilities: ______

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Reason for leaving: ______

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Position/Title: ______Employment Dates: ______

Company/Family: ______

Address: ______

Supervisor: ______Phone: ______

Email: ______

Describe your responsibilities: ______

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Reason for leaving: ______

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Position/Title: ______Employment Dates: ______

Company/Family: ______

Address: ______

Supervisor: ______Phone: ______

Email: ______

Describe your responsibilities: ______

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Reason for leaving: ______

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Education

School Location DegreeProgram of study Graduate?

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Languages

LanguageFluentConversational

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Circle all that apply

CPR certifiedFirst Aid certifiedLife Guard certifiedLicensed to drive

List any other certifications

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Describe your ideal position: ______

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Circle those things that you have experience with.

ChildrenMeal PrepFamily Care

0 – 6 monthswarming breast milkpet care

6 months – 2 yearsmaking formulahouse maintenance

2 – 5 yearsmaking baby foodcar care

5 – 9 yearsmeal prep for toddlersvacation packing

9 – 14 yearsmeal prep for childrenevent planning

15 years and upfamily mealserrands as needed

Special CircumstancesChildren’s NeedsHousekeeping

Twinsactivity planningdishes

Multipleshomework helpsweeping /vacuuming

Allergiesplaydate supervisionclean kitchen counters

Asthmabedroom cleaningclear clutter

Autismchildren’s laundryfamily laundry

Intellectual Disabilitychildren’s pressingfamily bedding

Physical Disabilitymedical appointmentsdusting

Emotional Disabilityschool appointmentsclean bathrooms

Specific Medical Needscarpoolingmaintain outdoor areas

Are you willing to travel with the family? ______

Do you have a U.S. passport? ______

Do you have travel limitations? ______

What is your general weekly availability?Are you available for overnights?

Sunday / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday

What is your ideal commute? ______

Are you able to drive for work? ______Are you willing to use your own vehicle? _____

Is your driving record clean? ______

Are you experienced in cooking for special diet needs?

VegetarianVeganGluten FreeKosherHalalOrganic

Personal Statement:

What are some activities you enjoy engaging infants in? (2-3 months)

What is a healthy meal for a two year old?

How can you help a five year old understand addition?

When caring for a seven year old, they fall and bump their head. What do you do?

You are caring for a three year old and a seven year old, you need to clean up from the afternoon and prepare dinner for the children. The family has a puppy that also needs your attention. It is 4:30 p.m., describe how you get everything done before 6 p.m.

What do you believe is the most important part of caring for children? (Circle one)

Keeping them safe

Keeping them happy

Keeping them engaged

Describe a challenge you have had in the past caring for children. What happened? How did you move past the challenge? Would you do anything different now?

What do you enjoy about being a nanny?

Do you have any plans in the next 18 months that may interfere with you accepting and keeping a position?

What needs or expectations do you have of a position to be happy, engaged and loyal for the next 2 years?

Is there any additional information you would like to add?

Thank you for taking the time to initiate the candidate process!

The information listed above is true and accurate to the best of my ability.

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