First name:    Last name:

Address (street, city, zip code)

Home Number   Work   Cell

Fax Number   Email address

Best time to reach you    Start Date:

Occupation of mother and father

Type of Services  (Live in/out, cleaning services, maid services, laundry services, organizer)

Weekly Budget ($200.00, $300.00 etc.) $   Number of hours per day   Number of days required

How many children do you have?   Do you have pets?

Does your child or children attend school?   Does candidate have to pick up child or children?

Ages of child or children

Does your child or children requires special care?

Will candidate share the same bathroom as you and your family?   or does candidate have their own room/bed to sleep in?

Should candidate know how to drive or have a driver's license?

What personality types or persons are you looking for?

What age group should your candidate range (ex: 25-30)

Number of parent (s) in household (husband, wife, single parent etc.)?

Budget ICS should consider as a replacement fee?

How did you hear about us (Yahoo, Google,  Friend, Newspaper etc.)?

Are you requesting a pet friendly candidate?

Provide additional information we should know about you and your requirements?

We ask that you provide the information requested above so that we can provide you the appropriate candidate. Failure to do so may result in unsatisfactory placement.