Clients: Cass & Company Domestic Staffing Agency Boston Massachusetts MA Providence Portsmouth RI CT VT NH ME New Hampshire Maine Connecticut Vermont New England Rhode Island

Home/Employer Information:

Client or Corporation Name(s):

Spouse Name (if applicable):

Home Address:

City:

State, Zip:

Home Phone:

Home Fax:

Home Email:

Other addresses employee may work or live:

Employment information:

Occupation:

Spouse's Occupation :

Employed by:

Work Phone :

Work Fax:

E-mail:

Job Description:

PART ONE -- Include all aspects of childcare, adult care or homecare needed, for example: Names of individuals to be cared for, their needs, ages, any special needs (physical, educational, emotional, behavioral, other) and their schedules. (Please use another piece if paper if necessary).

Days & Hours of position to work :

Any flexibility in hours needed ? (Please define)

Approximate salaries (Please give us a range. Please do not put negotiable ):

Is car provided?

Yes No

Is this for use while the individual is off duty as well as on duty?

Yes No

Holidays paid:

Vacation (# weeks):

Other benefits offered (Travel, Health Insurance, Bonuses, Tuition, Reimbursement, Use of Vehicles, etc.):

PLEASE CHECK ALL AND ANY THAT APPLY TO YOUR POSITION.

Schedule of Position:

Full time

Part time

Live In

Live Out

Live Out, (would stay over when needed)

Type of Position:

Nanny (See below)

Nanny/Housekeeper

Household Manager

Estate Manager

Housekeeper/Child Care

Housekeeper/Adults only

Companion/Elder Care

Mother's Helper

Chef/Cook

Other

Duties of Position (Nanny only position)

Children's only

All housekeeping (See Below)

Childcare/Light Housekeeping

Children's laundry
General pickup
Clean up kitchen
Empty dishwasher
Keep bedrooms clean
Make beds
Make meals
Occasional errands
Driving children
Pick up toys
Pick up toy room

Household Manager - everything to the left and below, plus floors, scheduling appointments, etc. (varies for each family)

Days / hours needed to work:

***Please check only job responsibilities that your position requires: ***

HOUSEKEEPING:

Wash Walls	Wash Windows	Clean Bathrooms	Mop Floors
Clean Kitchen	Make Beds	Mother's Helper	Set Table
Wash Dishes & Pans	Wash Linens	Polish Silver	Iron Clothes
Hand Wash Clothes	Iron Shirts	Wash Clothes
Dust	Vacuum	Iron Linens

COOKING:

Gourmet Cooking	Plain Cooking	Family Serving	Menu Planning
Prep Assistant	Special Diet Cooking	Family Cooking	Formal Serving

HOUSEHOLD MANAGEMENT:

Supervise Staff

Hire Staff

Shopping

Errands

Computer Skills:

Other duties the employee may need to perform:

Non-Smoker?

Yes No

Driver?:

Yes No

CPR?

Yes No

First Aid?

Yes No

Must own their own car?

Yes No

Is this a uniformed position?

Yes No

Do You have pets?

Yes No

If yes, what kind?

Is there any pet care?

Yes No

If yes, what?

Any travel?

Live-in accommodations (if applicable):

Are there any lanuages spoken in your household besides English? If so, please specify:

Are there any restrictions in this position:

*** Is there anything else about your family that we should know (schedules, hobbies, illnesses, marital problems, etc.) that could enhance our placement strategy and make a better placement?

Please describe the area(s) you live in: (State & Area)

Please list two references that we or the prospective candidate can call for a reference. (One could be a current or past employee.)

(1) Name:

Telephone number:

(2) Name:

Telephone number:

Indemnity Agreement:

The above information describes the position I/we are requesting Cass & Co, LLC to fill by searching for and referring candidates to be employed by me/us. I/we agree to abide by all of Cass & Co, LLC policies, contracts, and agreements . While Cass & Co, LLC endeavors to use its best efforts to recruit and refer qualified applicants that the company believes will accommodate my requirements and particular needs, I understand that the company cannot warrant that the information provided to it by the applicants is true and accurate, or that my employee will perform his/her duties to my satisfaction or will otherwise be suitable for my or my family's specific needs. By signing this agreement I understand and agree to release and discharge Cass & Co, LLC, and its officers, directors, and agents, from any liabilities, losses, obligations or damages incurred by me as a result of its referral, or by my employment of anyone through Cass & Co.LLC

Check to agree and enter your name here for signature.

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