EmailMe Form - INDIGO LIFESTYLE SOLUTIONS

CONTACT INFORMATION

Today's Date

MM / DD / YYYY

Legal Name *

First Last

Name you like to be called

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Home Phone #

### - ### - ####

Cell Phone #

### - ### - ####

Best # to reach you

BACKGROUND INFORMATION

Citizenship Status

Social Security Number

Date of Birth *

MM / DD / YYYY

Emergency Contact Name

First Last

Emergency Contact #

### - ### - ####

What is your native language?

Can you communicate well in English?

Yes

No

Somewhat

How would you describe your general health?
Do you live a healthy lifestyle? Explain:

Do you have a valid drivers license? *

Yes

No

Drivers License #

Do you have your own car? *

Yes

No

What kind of car do you drive?

Please state year and model

Do you have any traffic violations? *

No

Yes, with explaination

Have you ever been arrested? *

No

Yes, with explaination

EMPLOYMENT PREFERENCES

Please tell us what you are looking for in your next position:

Position(s) Qualified for

If other please explain:

Which are you seeking?

Full Time

Part Time

Live in

Live out

check all that apply based on availability

If part time, what days can you work?

If part time what hours can you work?

What date can you begin a new position?

MM / DD / YYYY

How long can you commit to a new position?

One Year

Two Years

Longer than 2 years

Less than 1 year

What is your salary range per hour?

What is your salary range per year?

Are you willing to use your car for work purposes?

Yes

No

Will you work in a home with smokers?

Yes

No

Will you work in a home with pets?

Dogs are ok

Cats are ok

All pets are ok

I do not work well with any pets

Please describe your skills based on your experience and the position (s) you are seeking:

If you were to design the perfect position for yourself, what would it look like?

Please state any other outstanding talents or skills that would make a family chose you over another candidate?

For example: I am a swimmer, I love to travel, I play the piano etc.

How would your best friend describe your personality?

WORK EXPERIENCE

Please list your last 3 employers.
Begin with your most recent position.

1. Name of Employer *

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email

Please tell us in detail what position you had and what your duties were. If there were children in the home, please indicate the ages of each child. *

Start Date *

MM / DD / YYYY

End Date *

MM / DD / YYYY

What was your salary range from start date to end date? *

Why did you leave? *

2. Name of Employer *

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email

Please tell us in detail what position you had and what your duties were. If there were children in the home, please indicate the ages of each child. *

Start Date *

MM / DD / YYYY

End Date *

MM / DD / YYYY

What was your salary range from start date to end date? *

Why did you leave? *

3. Name of Employer *

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email

Please tell us in detail what position you had and what your duties were. If there were children in the home, please indicate the ages of each child. *

Start Date *

MM / DD / YYYY

End Date *

MM / DD / YYYY

What was your salary range from start date to end date? *

Why did you leave? *

EDUCATION

Name of High School

City, State and County of HS

Did you graduate HS?

No

Yes: Insert year below

Please list any college experience or other professional training you have had. Include degrees, areas of study and/or certifications:

If you have a resume, please upload it here

If you have any letters of reference that you would like to share please upload them here.

If there is anything else you would like to share, please feel free to do so at this time.

Who referred you to our office or how did you find us? *

CONTACT INFORMATION

BACKGROUND INFORMATION

EMPLOYMENT PREFERENCES

WORK EXPERIENCE

EDUCATION

Thank you for taking the time to apply to our agency. Someone will contact you shortly to set up a personal interview.