Please enter your information below:
E-mail:
Last Name:
First Name:
Middle:
Address:
City:
Zip:
Home Phone:
Cell Phone:
Referred By:
Nationality (Optional):
Religion (Optional):
Languages besides English:
Years in U.S.:
Children of own:
Age(s):
,
,
,
,
Married/Single:
Married
Single
Interests/Hobbies:
Can you read English?
Yes
No
Some
Can you write in English?
Yes
No
Some
Do you smoke?
Yes
No
Do you Drink?
Yes
No
° DESIRED POSITION:
Full Time:
Type in Time
Part Time:
Type in Time
Nanny
Mother’s Helper
House Mgr
Personal Asst
Housekeeper
Elder Care
Live In
Live Out
Full Time
Part Time
Permanent
Temporary
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
° EDUCATION
Name of School
City, State
Subjects
Year
Graduated
High School
College
Other
° CPR CERTIFICATIONS
CPR & First Aid
TB Test
Other
Exp Date:
Date:
° REVELENT EXPEREIENCE
Employment
Employer
Title
From
Mo:
Yr:
To
Mo:
Yr:
Full Time
Part Time
Live In
Live Out
Name:
City:
State:
Phone:
Cell:
Email:
Personal Asst.
Nanny
Elder Care
Housekeeper
Other:
Responsibilities
Members Cared For
Reason for Leaving
Housekeeping
Light
Full
# Rooms:
Books
Read Books
Art & Crafts
Laundry
Cooking
Personal Hygiene
Driving
Other:
No:
Age:
Age:
Age:
Age:
Twins:
Special Needs:
Salary:
$
Per
Employment
Employer
Title
From
Mo:
Yr:
To
Mo:
Yr:
Full Time
Part Time
Live In
Live Out
Name:
City:
State:
Phone:
Cell:
Email:
Personal Asst.
Nanny
Elder Care
Housekeeper
Other:
Responsibilities
Members Cared For
Reason for Leaving
Housekeeping
Light
Full
# Rooms:
Books
Read Books
Art & Crafts
Laundry
Cooking
Personal Hygiene
Driving
Other:
No:
Age:
Age:
Age:
Age:
Twins:
Special Needs:
Salary:
$
Per
Employment
Employer
Title
From
Mo:
Yr:
To
Mo:
Yr:
Full Time
Part Time
Live In
Live Out
Name:
City:
State:
Phone:
Cell:
Email:
Personal Asst.
Nanny
Elder Care
Housekeeper
Other:
Responsibilities
Members Cared For
Reason for Leaving
Housekeeping
Light
Full
# Rooms:
Read Books
Art & Crafts
Laundry
Cooking
Personal Hygiene
Driving
Other:
No:
Age:
Age:
Age:
Age:
Twins:
Special Needs:
Salary:
$
Per
AGENCY AGREEMENT BETWEEN APPLICANT/DOMESTIC WORKER AND TLC AT HOME. YOU SHOULD READ THIS ENTIRE AGREEMENT CAREFULLY T. This Agreement is required by California law in order to clarify that TLC at Home is not your employer. You are referred to herein as the “Domestic Worker”. This Agreement is entered into on the date indicated below by and between TLC AT HOME, LLC (“Agency”) and myself. Agency will assist Domestic Worker in securing work. Domestic Worker is free to renegotiate with the person hiring Domestic Worker the amount proposed to be paid for the work. Agency’s referral fee will be paid only by the potential employer. Domestic Worker will not be charged a fee by Agency and the Domestic Worker is not responsible to pay the referral fee if the person to whom domestic services will be provided does not pay the referral fee to Agency. Agency will not pay Domestic Worker for domestic services performed, if the people for whom domestic services are performed do not pay Domestic Worker. Domestic Worker may be obligated to obtain business permits or licenses, where required by state or local law, ordinance or regulation. Domestic Worker is NOT eligible for .unemployment insurance, state disability insurance, social security, or workers’ compensation benefits through Agency. If Domestic Worker is self-employed, Domestic Worker is required to pay self-employment tax, state tax, and federal income taxes. Domestic Worker will not receive any training or equipment necessary to do domestic work from Agency with respect to the performance of domestic work. Domestic Worker will perform domestic work without any direction, control, or supervision exercised by Agency. Agency may take all of the following actions without being deemed to be controlling the manner and means of performing the domestic work: (1) inform the Domestic Worker about the services to be provided and the conditions of work specified by the person seeking to hire the Domestic Worker; (2) contact the person who has hired Domestic Worker to determine whether that person is satisfied with the Agency’s referral service; (3) inform the Domestic Worker of the time during which new referrals are available, or (4) request that the Domestic Worker inform the Agency if the Domestic Worker is unable to perform the work accepted. Domestic Worker shall inform Agency, if the Domestic Worker is unable to perform any work accepted by Domestic Worker and give at least two week notice before terminating assignment. The relationship between Domestic Worker and the person for whom domestic work will be performed will only be terminated by either of those parties and not by Agency. However, Agency may decline to make additional referrals to Domestic Worker, and Domestic Worker may decline to accept a particular referral. I, agree that during the term of my commitment with TLC at Home, LLC Services, I will maintain direct contact with the staff regarding my employment status. If any provision of this Agreement is determined to be illegal or unenforceable by the Court of competent jurisdiction, said provision shall be deemed stricken and the remaining portion of the Agreement shall remain in full force and effect. This Agreement shall be construed under the laws of the State of California, and any litigation initiated to enforce the terms of this Agreement shall be brought in the state and federal courts of Orange County, California. If litigation is commenced to enforce the terms of this Agreement, the prevailing party in such litigation shall be entitled to recover its attorneys’ fees and costs incurred in such litigation. I understand and agree that should TLC At Home, LLC decide to institute legal action against me in respect of this Agreement, I will reimburse all expense incurred by TLC At Home, LLC, legal costs arising from such an action, inclusive but not limited to attorney’s fees. This Agreement contains the entire Agreement between Agency and Domestic Worker and supersedes any prior or contemporaneous written or oral agreements. This Agreement may only be modified in writing signed by both parties I agree that if and when a Client has contracted me for an interview and or offers me a permanent position either on a full time or part-time basis, I will notify TLC At Home, LLC within 24 hours of such as offer. I further agree that I will not accept employment with a Client outside of my commitment as stipulated herein without the knowledge and mutual consent of TLC At Home, LLC. I agree not to falsify any information and or details regarding any and all discussion pertaining to employment offers made to me by said Client of TLC At Home, LLC. I understand that failure to notify TLC At Home, LLC, or to abide by these guidelines may result in TLC At Home, LLC instigating legal action against me together with the Client who employs my services without directly arranging such employment through TLC At Home Services, LLC. BACKGROUND CHECK DISCLOSURE As part of the employment process, TLC At Home may obtain a criminal and / or consumer report and / or investigative consumer report. The Fair Credit Reporting Act as amended by the Consumer Reporting Reform Act of 1996 requires that we advise you that for the purposes of employment, a consumer report may be made which may include information about your credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided in the event the Report contains information regarding your character, general reputation, personal characteristics, or mode of living. ♥ Authorization and Release of Employment Verification : During the application process and at any time during any subsequent employment, I hereby authorize U.S. Information Search on behalf of the Agency to procure a Criminal Report and / or Consumer Report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may include Criminal Records, Credit reports, Driving Records, Past Employment or Education Verifications, Worker’s Compensation Claims, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification; to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original, fax, or copy form. _____Oklahoma Applicants only: Please check here to have a copy of your Consumer Report sent to you from USIS. Mail a copy of this request with this box checked off to U.S. Information Search at 15 North Mill Street, Nyack, NY 10960. Include in the envelope a copy of your Driver’s License (for identification) and an address to where you would like the report mailed _____California and Minnesota Applicants Only: Please check here to have a coy of your consumer report sent to you form USIS. Mail a copy of this request with this box checked off to U.S. Information Search at 15 North Mill Street, Nyack, NY 10960. Include in the envelope a copy of your Driver’s License (for identification) and a $5.00 check or money order (for processing) and an address to where you would like the report mailed.
I have read and agree to the above
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