Heartland Nannies Agency Preliminary Application for Nannies
PO Box 1582 - North Platte, NE 69103-1582     Phone: 800-336-9783 or 308-532-7504   Fax: 308-532-2841
 
Today's Date Position applying for
Date of Birth Social Security #
E-mail Address Willing to Relocate
Could Start work Work Period to End
Last Name First Name
Middle Initial Maiden Name
Present Address Street Address
Apartment #
City  State
Zip Code
Phone:
Alternate Phone:
Fax:
To Attention of:
 American Citizen     If Not >  Resident Alien with a Green Card
Check all of the following that apply:
Drive a Car
Driver's License #
State of Issue
Swim  
Know First Aid  
Know CPR  
Smoke        If Yes   Socially (with friends)     Openly
Maximum number of children, regularly part of household, you are willing to care for.
I am experienced at working with children from ages  to
I prefer to work with children from ages   to
I am willing to work with (Check all that apply):    
Twins      
Triplets      
Physically and/or mentally handicapped  
Elderly      
Are you willing to work around animals? Prefer to Prefer not to
Cats Dogs Birds Fish
Horses Rabbits Rodents Reptiles
  Reason for preference:
What do you enjoy doing in your free time?
In What capacity of CHILDCARE have you had experience?  
Neighbors Camp Counselor Church Teacher Live-out Nanny
Live-in Nanny Church Nursery Day Care Center
Relatives Other  
Are you experienced and willing to help with the following household chores should they become part of your job description?
General Housekeeping Laundry Ironing
Prepare simple family meals Grocery Shopping
How would you rate your overall health?
Are you willing to complete a medical statement?   Yes    No
Give names and complete mailing addresses of at least three families you have baby-sat or nannied for:
  Name of Family
  Street Address
Apartment #
City  State
Zip Code
Phone:
Alternate Phone:
       
  Name of Family
  Street Address
Apartment #
City  State
Zip Code
Phone:
Alternate Phone:
       
  Name of Family
  Street Address
Apartment #
City  State
Zip Code
Phone:
Alternate Phone:
       
Highest Level of Education:    
High School Diploma    
Some College    
College 2 year Degree    
College 4 year Degree    
Subjects of special study:
Will you live in any geographical area if you find the perfect family? Yes    No
Comment on why you feel you would make a good nanny:
       
I hope to make from $ to $ per week to start.   Salary open or negotiable
       
 
 
The Heartland Nannies Agency will email you within 72 hours to confirm the
information you have submitted has been received. Thank you!

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