Las Vegas Domestic Specialists
Client Pre-Application

Please take a few minutes to fill out this form and send it to us.
One of our experienced placement counselor will get back to you
within one business day.
Thank you.


FIRST NAME:    LAST NAME:

ADDRESS:

CITY:   STATE:   ZIP CODE:

HOME PHONE:   CELLULAR PHONE:

WORK PHONE:   FAX:

E-MAIL ADDRESS:

HOW MANY INDIVIDUALS RESIDE IN YOUR HOME?
ADULTS:  CHILDREN:

CHILDRENS AGES:

ANY SPECIAL NEEDS
YES    NO
IF YES PLEASE EXPLAIN:


LANGUAGE SPOKEN?
ENGLISH SPANISH ITALIAN HEBREW OTHER

DO YOU HAVE ANY PETS?
YES    NO
IF YES WHAT KIND?


DO YOU REQUIRE SPECIAL CARE FOR ANIMALS?
YES    NO
IF YES, PLEASE EXPLAIN


WHAT POSITION ARE YOU INTERESTED IN FILLING?
NANNIE   HOUSEKEEPER    ELDERLY CARE

FULL TIME OR PART TIME?
FULL TIME (over 30 hours)   PART TIME (less than 30 hours)

PERMANENT OR TEMPORARY?
PERMANENT   TEMPORARY    ONE TIME

LIVE-IN OR LIVE-OUT?
LIVE-IN   LIVE-OUT

DAYS REQUIRED: HOURS REQUIRED: