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Employer Registration Form

Title

Employer Name

Address Line 1

Address Line 2

City

Zip Code

Home Phone

Business Phone

Cell Phone

Email Address

Type of Position

Live In Live Out

Permanent Temporary

Days & Hours Requirments

Estimated Starting Date

Estimated End Date

Number Of Children

Age Of Children

Qualifications Required

Duties And Responsibilities

Drivers License Required?

Yes No

Car

Provided Own

Pets

Yes No

Need To Be Walked Out?

Yes No

Do you allow smoking?

Yes No

Do You Travel As A Family? If So, How Often, Would The Childcare Provider Need To Accompany You Or Would The Time Off Be Paid?

Do Any Of The Parents Work From Home?

Yes No

Which Of The Following Do You Provide?

Paid Holidays Paid Overtime

Paid Vacation Annual Review

Sick Days

How Did You Hear About Lakeview Domestic Agency?

Please submit this form

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