Emergency Name


Emergency Phone


Position Required


Location Desired


Will relocation be with spouse/children/animals?


Please Explain

Live-In/Live-Out
Live-In   Live-Out

Date of Birth

Are you a Citizen of U.S.A?
Yes   No

If not, send a copy of Green Card(s)/work visa etc. If foreign born, but U.S. Citizen, send copy of U.S.A Passport.

Do you or any family member smoke?
Yes   No

Will you work in a smoking residence?
Yes   No

Allergies to animals or any allergens?

Any health issues? (Please Explain)


Yearly Salary Parameters
$35 - $50K   $50 - $75K   $75 - $100K   $100K - Up

Worked in homes with staff?
Yes   No

How many? (Please explain)

Formal or Informal Service

How did you hear of Hawthorne Domestics?

NOTE: * Please send a copy of resume showing residence and size of house, and/or properties acreage you have worked in along with copy of driver's license (if a couple please send copy of each one) along with a very recent photo - write your name(s) on back and date photo was taken.

TAXES - Please Note: Your employer is required to deduct your portion of all Federal and State Taxes.

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