Salem Sitters - Baby Sitters, Pet Sitters, House Sitters in Winston-Salem NC.

Layout

Employment Application

Personal Information

First Name
Last Name
Middle Name
Maiden Name
Social Security Number
Other Name(s) Used	(Nickname)
Home Address
City
State		Zip Code
Home Telephone
Business or Cell #
Email Address

Position Desired - Multiples possible
Referred By
Have You worked with special needs children
If yes, in what area (Deaf, ADD, ADH, etc.)
Are you a U.S. Citizen
If no, are you eligible to work in the US
Do you have any relatives employed by the company
If yes, list their name
Are You At Least 18 Years Old
Do You Smoke?

Education

Highest Level of Education Completed
High School	9 10 11 12
College	1 2 3 4

High School Attended
Address
Major Studies
Degree, Diploma, License or Certificate

College University
Address
Major Studies
Degree, Diploma, License or Certificate

Vocational, Business, Other
Address
Major Studies
Degree, Diploma, License or Certificate

Employment History- Must provide at least two references (not related to you)

Reference 1

Start Date		End Date
Employer Name
Employer Address
Supervisor Name
Supervisor Phone
Starting Salary		End Salary
Job Title
Reason for Leaving
Duties and Resp.

Reference 2

Start Date		End Date
Employer Name
Employer Address
Supervisor Name
Supervisor Phone
Starting Salary		End Salary
Job Title
Reason for Leaving
Duties and Resp.

Emergency Contact Information

Contact Name
Relationship
Home Number
Cell Number

References (preferable childcare)

1.

Name
Relationship
Home Number
Cell Number

Name
Relationship
Home Number
Cell Number

Name
Relationship
Home Number
Cell Number

Availability - Indicate all available days and times (ex: 2:00PM-3:00PM)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Miscellaneous

How many hours a week would you like to sit
What age children would you like to work with
Are you available at least two weekends a month
Maximum # of children you can work with
Are you willing to work special events/holidays
Are you willing to make meals during shift
List any outside dates you can't work
Are you willing to do Laundry/Dishes
When can you begin work
Rate of pay you would like

General

May we contact your current employer/personal references for past work experience?
If hired, will you be able to work overtime?
Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation?
Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged or seals by court? (A yes response does not automatically disqualify your application.)
Do you understand that corporal punishment (spanking) is an unacceptable form of discipline and should not be used under ANY circumstances while a child, adult, or pet is in your care.

Certificate and Authorization

This shall be deemed an integral part of the agreement between the sitter and SalemSitters, LLC. The sitter hereby represents and agrees that the relationship between the sitter and SalemSitters, LLC, is that of independent contractor and no agency relationship has been or will be created between them. The sitter agrees to denitrify and hold harmless SalemSitters, against any and all damages, claims, actions, cost and expenses, including attorney's fees, asserted by an person and arising out of or otherwise relating to the rendering of, or failure to render, any service by SalemSitters, LLC or the sitter.

I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize the Company to obtain any credit and consumer check.

The above information is true and correct. I understand that, in the event of my contract is accepted by SalemSitters, LLC, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.

The sitter further agrees that for a period of one year following the termination of the agreement with SalemSitters, LLC for any reason, the sitter will not work for any client of SalemSitters, LLC, unless first obtaining the consent of SalemSitters, LLC and agreeing to work for such client in full compliance with the procedures and requirements of the sitters agreement of Salem Sitters, LLC then in use. I hereby acknowledge that I have read and agree to the above statements. By submitting this form you are agreeing to all of the above statements.

Signature

I accept the Certificate and Authorization terms

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