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Granny NANNIES Contractor Application
Personal Information
*First Name:
*Middle Initial:
*Last Name:
*Social Security Number
*Date of Birth
*Address Line 1:
Address Line 2:
Apt./Unit Number
*City:
*State:
*Zip Code:
Home Phone:
*Cell Phone:
*E-Mail:
*Emergency Contact Name:
*Emergency Contact Phone:
 
Position & Availability
*Have you ever worked for Granny NANNIES?
If Yes, which location?
Position applying for?
CNA HHA RN OTHER 
*Date available to start?
*Are you willing to work weekends?
Yes No Occasionally 
*How far will you travel for a case?
 
Driving History
Granny NANNIES will be checking your driving history. Untruthfulness will cause you application to be immediately rejected.

Vehicle Year, Make, Model, & Color
DUI within last 3 years?
Yes No 
Reckless Driving within last 3 yrs?
Yes No 
Moving Violation(s) within last 3 yrs?
Yes No 
If Yes, how many Moving Violations?
Accidents within last 3 yrs?
Yes No 
If Yes, how many Accidents?
If Yes to any of the above, please explain:
 
Criminal History
Granny NANNIES will be checking your criminal history. Untruthfulness will cause you application to be immediately rejected.

*Felony conviction(s)?
Yes No 
*Theft related conviction(s)?
Yes No 
*Drug related conviction(s)?
Yes No 
*Violence related conviction(s)?
Yes No 
If Yes to any of the above, please explain:
 
Fitness Capability
*Have you ever been injured on the job?
Yes No 
*Can you stoop, bend & lift up to 25lbs?
Yes No 
*Ever recieved workman`s compensation?
Yes No 
If Yes, when?
If Yes to above, please explain injury and describe current physical status:
 
Education
Inaccurate information will delay the processing of your application.

*Diploma Received:
Diploma Equivalency (GED) Degree None 
College Name/Location:
Degree Earned:
Attended from:
Attended To:
Major/Minor:
 
Employment History (Last 3 Employers)
Inaccurate information (Example: wrong phone number) will delay the processing of your application.
Please notify your work references that a Granny NANNIES representative will be contacting them.
*Name Of Employer:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip Code:
*Employed From:
*Employed To:
*Job Title:
*Reason For Leaving:
*Supervisor Name:
*Employer Phone:

*Name Of Employer:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip Code:
*Employed From:
*Employed To:
*Job Title:
*Reason For Leaving:
*Supervisor Name:
*Employer Phone:

*Name Of Employer:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip Code:
*Employed From:
*Employed To:
*Job Title:
*Reason For Leaving:
*Supervisor Name:
*Employer Phone:
 
Professional References
Please list three references that have personal knowledge of you.
Do not duplicate anyone used in the Professional Reference Section.
Inaccurate information (Example: wrong phone number) will delay the processing of your application.
Please notify your personal references that a Granny NANNIES representative will be contacting them.

*Reference Name:
*Relationahip:
*Phone:
*Reference Name:
*Relationahip:
*Phone:
*Reference Name:
*Relationahip:
*Phone:
 
Equal Opportunity Agency Policy
Granny NANNIES does not discriminate against applicants on the basis of race, color, religion, sex, national origin, political affiliation, sexual orientation, gender identity, marital status, disability and genetic information, age, membership in an employee organization, or other non-merit factor except as provided by law or when such requirement constitutes a bona fide occupational qualification necessary to perform the tasks associated with the position.
Background Authorization and Signature
I certify that all of the statements made in this application are true and correct, and that I have not misrepresented or withheld any information. I understand that the falsification of this information may result in immediate dismissal. I further acknowledge that any contract offered to me or which I accept is a contract at will and may be termainted by me or by the company at any time, with or without cause or reason. I understand that any offer of a contract may be contingent upon a background investigation which may include criminal, motor vehicle or previous employment. I hereby authorize all references and former employers listed on my application to give the company any and all information concerning my previous employment and any pertinent information they might have, personal or otherwise, and release all parties from any claims, causes of action, or liability from damages that may or could result from furnishing such information to the company.

*Choose One
*Name
*Enter Your Initials
 
 

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in UPPER CASE.
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