Domestic Employee Application

Please complete the following Domestic Employee application and the Domestic Employee agreement. Please print, fill in your info, sign, scan and return via email to: with a copy of your driver’s license.

Name: _____________________________________________ Date:________
Work Phone:___________________________ Home Phone: __________________________

Cell Phone ___________________________ Email address ___________________________

Current address: Street: _______________________________________________________

City: ___________________________________ State: ________ Zip:__________________

Social Security #:________________________ Green Card ID#: _______________________

Job Applying for:

___ Personal Assistant
___ Chauffeur
___ Estate Manager
___ Housekeeper
___ Couple
___ Personal Chef
___ Laundress
___ Baby Nurse
___ Butler
___ Nanny

Please describe experience in the above field:

Driving/ Personal Habits:

Valid Diver’s License:____________________ State:________________________________

License #:__________________________________________________________________

Number of accidents/moving violations in which you were a driver in the last 3 yrs:___________

Have you ever been convicted of a crime:_________________ Explain:____________________________________________________________________

Do you drive a stick shift?____ Can you bring a car?____________

Do you smoke?______ Do you drink alcoholic beverages?___________

Dietary restrictions: __________________________________________________________

CPR: ________________

Other special qualification: _____________________________________________________


How is your general health?____________________________________________

What is your energy level?_____________________________________________

Do you take any prescription medications?________ What for?_______________

Allergies:____________ Psychological problems?:_________________________

Are you physically able to do this job?___________________________________


Highest level of education:_______________________________________


Special interests:_______________________________________________

Do you like pets?____________


Past employment:

To: From: Family Name: Phone #: Reference:

________ _______ ________________ _____________ _________________

________ _______ ________________ _____________ _________________

________ _______ ________________ _____________ _________________

Permanent address:

Permanent phone:___________________


I __________________________________acknowledge that you have advised me that you may request a reference check which may include information on my character, general reputation, education, personal characteristics, driving record, police record, and past employment. I hereby authorize you to obtain such a report. I acknowledge that I have read and understand this statement and all statements made, and the information provided on the employment application, of which this is a part, are true to the best of my knowledge. I agree to release and promise to hold Nanny Agency of the Hamptons Inc. harmless for any act of the employer. I also agree to hold Nanny Agency of the Hamptons Inc. harmless of any claim as a result of the placement.

Applicant’s signature:____________________________Date:___________

Agreement between (“Employee”): _____________________ and Nanny Agency of the Hamptons Inc., a licensed and bonded employment agency in the State of New York.

Nanny Agency of the Hamptons acting solely as a referral agent and at no time will be the employer. The Nanny is under no obligation to accept any referral to or a job from anyone Nanny Agency of the Hamptons Inc.refers the Employee to.

I hereby certify that my claimed identity is genuine and true and I also certify that all the information in the application, essays and additional information given to Nanny Agency of the Hamptons added means is true in all respects.

I hereby relinquish all claims or possible liability from Nanny Agency of the Hamptons Inc. At no time will Nanny Agency of the Hamptons Inc. be held responsible for any damage or loss resulting from employment from a Nanny Agency of the Hamptons Inc.referral, including any acts of commission or omission on my part or the part of the employer family. I also agree that Nanny Agency of the Hamptons Inc. will not be held liable for the reimbursement of any fees arising from traveling to or from the set job or any possible court costs or lawyer fees stemming from any claim that may be made by any person.

I understand that I must inform Nanny Agency of the Hamptons Inc.of any contracts or job offers that may come about in the course of my job search including the acceptance of a position. Nanny Agency of the Hamptons Inc,is not obligated to find me a position and will not be held responsible if an employment is unsuccessful.

I agree to keep all information given to me about prospective employers confidential and will continue to keep that confidential at all times in respect for the families’ privacy.

I am aware that I am responsible for the travel expenses and travel arrangements to relocate to the said employment and will make my own agreement with my employer for reimbursement or other compensation.

I understand that I am not required to pay a fee of any kind for the referral services of Nanny Agency of the Hamptons Inc. I understand that the Nanny Agency of the Hamptons’ Inc.referral fee is the obligation of my employer. I am aware that there is a contractual agreement between Nanny Agency of the Hamptons Inc.and my employer and understand that I may not arrive at the employer’s home until such conditions as set in the agreement between Nanny Agency of the Hamptons Inc. and my employer.

I understand that I am being asked to make at least a ____________ month commitment to which ever family I decide to be placed with and am willing to do so. I am able to start work on:__________________ and terminate work on: _____________________________.

I agree to follow the rules laid down by the American Arbitration Association stating that any problems or breeches of contract arising from this agreement must be settled by arbitration and any judgment made by the arbitrators may be entered in any court having jurisdiction thereof.

I understand that Nanny Agency of the Hamptons Inc.and my employer will rely on information which I provide on my application, forms provided by Nanny Agency of the Hamptons Inc. and other records and/or statements which I may provide. I give permission to Nanny Agency of the Hamptons and any prospective employer to verify and use the information for employment purposes which I provide during an interview or in writing. I agree that NannyAgency of the Hamptons Inc. may cancel its agreement to assist me in finding employment and/or that my employer may dismiss me immediately if any part of the information is not true.

I understand that nothing in this contract is intended to guarantee that Nanny Agency of the Hamptons Inc.will find me a suitable position. If I accept a position as a result of a referral from Nanny Agency of the Hamptons Inc.and the job is unsuccessful, I understand that Nanny Agency of the Hamptons Inc. is not required to assist me in finding another job or to reimburse me for any expenses I may incur should I voluntarily or involuntarily leave my job.

I have read and understand all of the foregoing provisions of this contract and I confirm my agreement with all that is contained in the contract by signing my signature below:

Signature____________________________________ Date ______________________

for Nanny Agency of the Hamptons, Inc.:

Signature____________________________________ Date ______________________