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Voluntary Candidate Questionnaire Date re cea 2} O™ Nucanipra_ bee _ Cicky). ns ae Oo = ar RE i ae fae [636 Fox Hayward ¢ ge Po4Pawo AY os ‘Are you aS, Gi S32- 444 Ti jal ry are you from? Then did the US. r BR WB CUT 350". Tan you legally accept employment? GK BE ‘How long have ia aes = you dive a wi shift? FR Doyouhaveacat = oe Wake)Model ™ CN 19-95 ubjest az (Foe) ) CINo “Type of position desired lanny Personal Assistant wuschold Manager (Gece thee sph psby Ruse DBiccckecet Eigse: banwees Cook CBatler_ Other as, _ ER Rasee? Ages task? Date available to start new position: — SETS soon ad possi: Sauce mal 2,5 2, hvs. to S(neteafer taxes) Z omer ee Danes. 18-asfor Woot -dogauda On Pb ‘Tn what cities would you consider working? Meno Part, Paco Acro, Arreetow Repwwon CTY or Movustam View Voluntary Candidate Questionnaire ‘Would you be comfortable working with two clients who wanted to share your services? ‘Are you comfortable working with a parentJemployer in the ho Your name: ‘Are you comfortable working with a single parent/employer? ‘Are you comfortable working in a home with pers! ‘Would you considera position that inclades wavel? ‘Would you be willing to occasionally work extra hours? ‘Would you be willing t do an occasional overnight? Do you have any religious obligations, preferences or practices which would affect your job! “Whot duties ee you wiling to peonnt (Check all hat apps Tyee, please explaine Light housekeeping _ Driving children Toardening Biber care 7 Pe eee ig pad Bei ble final even planaing \Chilcens laud ocey hopping typing child related event planning Benin Ecrand running CRling (Scheduling service penonnl JIroning ersonal shopping mputer data entry (Supervising household staff [Mending ‘(Purchasing children’ clothing “[]Houshld bookeeping (iting household staff Tock (or children) Cooking (for family) How would you rate your cooking JBeginner ver, Sourmet = OF Pies Cosa ‘What type of food do you enjoy making? Education. Name of schoo! and location Dates attended (to/from) Degree/Major courses of study High school | Miao OTK 1423-96 Degeze. ‘Technical, vocational, business or raining College or University y Graduate shoal Mexico Cir [496-1999 4 DEGueE “Fat you curently taking: oat Ae a Oni AYA" (Occegz ‘Aekiional course work, seminars, walning or volunteer work we Boe Foture goals T wank wow fy a few youn and 7 word bact do school and take ‘Compe? Adm rearon Voluntary Candidate Questionnaire Your name: Health History “re you now in good heal RT ‘Date of last visie with a doctor Physician: Phone: Date Flat TE eat ory Have you ever fied for or received ‘Workers Compensation? If yes, describe and explain the work limitations If yes, when! ‘Do you have any physical imitations? Do you tke any prescribed medications? — Do you smoke! (if yes, specify amount and how often) Do you drink? (tyes, specify amount and how offen) Do you now, or have you ever been tated fora drug or alcohol problem Do you now have, or have you ever been told that you haves Anhalt ‘Cancer Diabacs Heat dia Henia “CRE pan or presare notional probleme Fligh Blood presse Epilepsy or convilsions ‘Skin diseases ining oF Uaaines “Allergies hay fever Frequent headaches ‘Chronic coughs or colde 1D you now have, or Rave you been treated for any back diowder oF injy? Fave you ever Been advised to change occupation or rsdence boca of each Do you ave any medical considerations? lave you had any major operations or UnessesT ‘Do you cary health Tnaurance” (iF yes, note Insurance company's name) Voluntary candidate Questionnaire ‘Your name: Ty ls Bec ache awing eran doe na ins your ogy To engl ‘Dsingle ~ EBivorced CiSeparated OWidowed ‘Flow ong have you been eee - ears CareRr eno Hore ent 1 gta Partner’ birplace Lexi to CH Cowsresct wat) WES COS youve de ™ Zc oo4s) Nang aes Schabl_- Ifyou have young children, do you plan to Bring them to werk with you! (Tye My wow 2 San OW lo Parle ese Taare Thy yor gow wp wT Actas, SHoak - Schadl TFnot who will care for them while you are working? Youu 1G nod - Hentea Cy - — ‘Your mother occupation: Your brothas and sists ae Mats Seel Lars . Name ‘Occupation’ [ory Bion Usk - hey AWA von Wogicd Cites ‘Fes Ta Tow of your lies nd ars ead, FRAY wir TH Mt Kis, aml WALK. Voluntary Candidate Questionnaire ‘lease Tse the Tanguages you speak fuendy Spasotl ¢ enapenil. Your names 41 (4a) A / AL ‘What pes of activities do you enjoy doing with children? lease share the reasons you enjoy working with children: ow do you manage dificule behavior? Is there any additional information you would like to share about yoursel®? ‘Do you play a musical instrument? Yes (No Doyouwin? Des No ‘Ans youegiimd wih Trained — EVex Wheat (No Fae you CPR ered? Lives Wheat Eipiaion de No ‘What ages of children do you feel comfortable working with? infant (under 1 yx) Citodier (I ye 10 ys. iow many children are you comfortable working with (one ne? TiPieschool Gy wo Sy) ischoat age (2 yr. to 10 928) Tischool age (10 yrs. to 13 yrs) (Teenager (13 yrs. +) ‘Are you comfortable working with ering? Lies No Voluntary Candidate Questionnaire Your name: Work History: Household experience "Work phon Work phone: ay Days worked: Satay ining News YO A,Gross Neb WGrss GO Date 5 compe Wouse _c ning | Noaberofbal Naber ef bathvoons Cir oons TK cnal ox — Ware tate ay oa elope We Fou 4 Be 2 —— Ne {you find this postion? (newspaper agency, 2) teeter Reason for Teaving * Grkwos- noado wele Wows m Addison Way we call our employer? Re _ ~xcfice we only CiReference Voluntary Candidate Questionnaire ‘Your name: Work History: Household experience Tengih of Employment ‘Work phone: _ ‘Occupation: oe A Mow ty A fo 3 eee te SrPap Finhing wlan, : Nev$ hy Grosss Nes RS Gross FO Duties “COMPETE HOE ATAR/NG. - Z SOLO - \taltaw Ghawu'c Cloots a SS ee ce Tae Fete Obes ae Ss CCasual ‘Were there way other employees in the houscbaldT Te iow did you find this position? (newspaper agency, ete: _—— = Dots wort | Ether ai ene EN Cloamor ature bor foc ofice ur only GiReference CEFECEWCE | Voluntary Candidate Questionnaire ‘Your name: Work History: Houschold experience a Tengih of Employment ET yg wr Piveou nes $O- GiGrox Net AS fps SO DS COMPLETE HOWE Cazanmig. (np 4+Zan, 3d arr cavTHey). TL Ree ae fal show Bayo LSE BY SEES Tonbinte lon. _ marae arenas? ts No Flow did you find this positon? (newspaper, agency, te) LEZ: for afice we only Likeference Voluntary Candidate Questionnaire ‘Your name: Work History Job tile Tengeh of Employment: EmployerCompany: Phone: Days work: Hours worked: Twice £ A HOw, to3- arg al = Faahing wh a we oss SO nes eae coms SOS OWS Cogan cee nures - Eefeléwsece Flow did you find is position’ (newapaper agency, Reason for leaving: faye al yor ensared Be - - - ____ONo _ - flim Cteferenee Jab ee Siartda Ede Tengah af Employment EraployeCompany ~~ Siparvison Phone Tacos - Cir Sate 7 Days worked - = Hoours worked Saving sary Rnahing aay : Nec$ : Cross Nec = Flaw di you Find this position! (newapaper, agency, Ct) Reason Tor eaving? May we call your employer? Tie - CNe Tor ofie we oly CDiReference Voluntary Candidate Questionnaire Work History ~~ Length af Employment Bays worked: Hours worked Ti 1cE_A_ Hon ttt.- We ASELN. crows Ne” ans 2Ahr. cron ComPttz —— pour.e cH Aming. 3 Stolen saa lary Nees Duties Flow did you ind this position? (newspaper eny oe _ Legil gots Tenn faving -_ ~ — Wael uel Gaye: varseatarene 7s omg hye Gases ofc eal DiReference Jobeeler Seared Tengih of Employment ployer Company, Days worked: Qece Awetze.-thye Na 50 = Grant ew ee Goss YOR Dass Cheae EI TCHEN, BarHtoeMs , Bedoors, Lyving $ re OY OOM cy = Spt Ac a CERELE OE | - Hodwn St Taree area Pre _ fdussh Vowo. ONo Taito oo DiReference Voluntary Candidate Questionnaire Your names Tandiord References (current and ggevious): ‘Aaldional reference information( non-relatives): Please dese your diving records CALAL. Have you had any accidents or walle Jyeg Tr, please explains voles? Be Fave you ever been convicted of [Yes misdemeanor or felony? lo Tfso, please explain (convictions do not necessarily disqualify you from employment): Person to notify in cave of emergency] cut he nd sive Form W-4 to your employer. Keep ho top pal fr your records, ram W-4 Employee’s Withholding Allowance Certificate OMB Ho sO stokes > or Princ Act nd Paperork Radian Act Mates, bn page 2 2000 Sa RTT ee _ Aina" SARC as) [ese"Focson Ae anne uhes Reet eee Fennel 03, 745¢q [kdwarescesacssnsesanenee ate : ‘Total number of alowances you are claiming (rom ine H above OR from the applicable worksheet on page 2) Et ‘ato aie fay yo wes en epee enon ne {pn esse oo bi le nae «Tet yar ad ego ela At Foie femur runes Bos 3 ane So AL For Peete ace ces gt —_ltyou mest both conditions, write “EXEMPT” heres. > [ry Eas te eee i tai TT TR TOT Ee eal 5 Ciiole Sat» cane I/D] 0 a sae | * tom Sa Was TORT a U.S, Department of Justice i future expiration date may also constitute Hhegal discrimination, Section 1. Employes Information and Verification. Tobe completed anf sgnod by oes Immigration end Natuazaton Serco i Employment Elgiblity Verication Pleage read Instructions carefully before completing this form.-|The = ‘must be avallable during complotion ot this form ANTPDISCRIMINATION NOTICE. Hs Meat To davritinaa agelhet work sleile anioesic” Erolopest GANNOT ‘specity wich document(s) they will accept from an employes. The refusal to hire an Individual because of & 1400 othe tine employment bagins PéntNome: tas Fist Wet [Maldon amg p wie Bm SANTILLAN Nicasbra (hz. iced Braz. x Wet F re op % moe oi Te item | Baeca Haywarn Cs" 1434g Sy 2- <7- {am eave hat teal Jan roa for | 5G peat Sy elf ct prisonment andor fines for false statements ot re United Stato Wao of fans ‘docarnome” Ie" cenwection aie the ‘Law pamofon! Resco (Aton # AD GE IEIS3D ‘Sompletion ofthis form. Aten suf owes rl Erpyeors Signatur, Brepagh ardor anal ion, (To bo ‘Pliyeestc my kroedbe ha neato had bre al para of ary, ta rave ai Prefrea/Transaiors Signature Pit ‘Ares (Soot Narva ed Wow, ily, Sala, Zp Ceca) Seelon =. Employer Review and Veriieaton, Tate pions oo} fxamine ono document from List B and one fram List Ce tod on te ove | ane fn gre rors tha ie, number and expat da, ary, fewein) List A OAR List iD List C Deeuneate Cade er bs Wes Iss author sun | SOC ime SE CTY Docent = Auwpee. Expiration Date fang fj wes a cima Briraion Data fYanyit J ‘employee, that the above-listed document(s) appear to be genuine ‘employes bagan omplayment on (monivdayiyea) —_j.__-vand th fe aigie 42 Wo In te United Sits. (Slats omivmert an land to t to the (best jelos. may omit te to the employee named, that the ‘of my knowledge the "employes the dato the employee bogan 1 GERTIFICATION - 1 attest, under penally of perjury, thet | have ae the ne) prosented by the ehove-named at employment). ‘Signature of Employer er Autonzea Represaniaive | Pan Name | To _l ‘asiness o Orgaization Nome ‘Adoress (Steer Rue unc Nurcba, Gy, Sita, Zp Code) [Data anveeyyear) Section 3. Updating and Reverification. Tobe carpet and ugnod by o "A. New Name (fapptaabiey (©. Wamployse's previous grant of work aulhorizefon has expiod, provide the inarmal clita. Document "Tie: Dresenied docamen Document #:__"Eapchton ato ‘attest, under ponaity of perjury. that to tha best of my knowledge, thie employes js sllgisio. SaaS de Manas Teas athe Sie sae HARTER io | p= el Tahica (rent aroar (i appteabioy af at Hen et ang Homi Tejhe Uelted States, and W the employes a a ‘Signature of employer or Auvorzad Papreseriaavo Bate fender —— Foam 9 (Rev. 112180) !

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