Mess Busters, Inc.
PO BOX 398926
Miami Beach, FL 33239-8926
5830 NE 6th Ct.,
Suite #100
Miami Beach, FL 33137
Phone 305-673-MESS (6377)
Fax 305-672-8326
Price: $200.00
Duties: (please check or write an X in the box)
Companion Driver Baby-sitter
Housekeeper Nurse Nanny
Personal Chef Butler Bartender
Please complete all blanks and circle where necessary. Return with deposit.
DATE: ________________________________________
NAME: ________________________________________
ADDRESS: ______________________________________________________
CITY: ___________________ STATE: _____________ ZIP: ______________
E-mail address: _____________________________
Entrance code #: _______________________________
Telephone: Home: _________________ Business: _____________________
Cell: ___________________ Beeper: ____________________
Fax: _________________________
Employer: __________________________________
Occupation __________________________________
Employer Address:
____________________________________________________________________
Spouse (Name): __________________________________
Occupation :_______________________________
Directions: Please state below specific directions to your home or place of interview from a major road near you.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How did you hear about us?
_______________________________________________________________
CHILD/CHILDREN:
NAME: ___________________________________
AGE: ___________________________________
GRADE: ___________________________________
HOURS IN SCHOOL: __________________________________
SPECIAL NEEDS:
Do you have any children with special needs? Yes No
If yes, please specify:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
DISCIPLINE:
Please specify the ways in which you discipline your children:
_______________________________________________________________________
_______________________________________________________________________
PETS
Do you have Pets? Yes No
If yes, what kinds: ___________________________________
Who takes care of your Pets?
_________________________________________________________________
PLACEMENT CRITERIA
(Please check)
Age 18-35 36-50 51-Over No Preference
Sex Male Female No Preference
Licensed Driver Yes No No Preference
Smoker Yes No Outside No Preference
Swimmer Yes No No Preference
Languages English Spanish Both Other
Do you require: (Please check)
Live in Live Out
Housekeeper Only Nanny Only
Nanny/Housekeeper Nanny/Light house keeping
Do you require a Placement with their own car?
Yes No
Will you be providing them with access to the family car?
Yes No
If yes, will you be covering them under your auto insurance?
Yes No
What salary will you be offering for your placement per week?
Desired salary ____________________
Maximum ____________________
Work Schedule: Please check: Days on
Mon Tue Wed Thurs Fri Sat Sun
Start time
M____ T____ W____ Thurs____ F____ Sat____ Sun____
Finish time
M____ T____ W____ Thurs____ F____ Sat____ Sun____
Hours per week:
Under 40 ____ Over 40 ____
ACCOMMODATIONS FOR LIVE-IN PLACEMENTS
(Please check all of the following accommodations that will be offered to your placement)
Own Room Separate Living Quarters
TV VCR Telephone Stereo
Preparation of meals: Yes No
If yes, Family Just Children
Do you observe any specific religious dietary laws or have any dietary restrictions in your home?
Yes No
If yes, would you be willing to teach your placement to prepare the meals according to your needs?
Yes No
Do you employ any additional domestic help in your home such as maids, cleaning services, etc.?
Yes No
If yes, please list:
___________________________________________________________
Will your placement be required to travel?
Yes No
If yes, will this be: USA Only Abroad
Do you require the placement to wear a uniform?
Yes No
Please list any additional benefits you might offer your placement:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Any other comments or special requirements:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Client agrees to notify Mess Busters, Inc., of the individual he/she has hired and the salary agreed upon. The client also agrees to refrain from hiring or contacting individuals that he/she interviewed for any other positions or jobs without the written consent of Mess Busters, Inc. In addition, after the individual has been hired, Mess Busters, Inc., will be held harmless for any damages to property during the independent contractor’s employment.
Agreed & accepted by:
________________________________
Print Name
________________________________
Client Signature
_________________________
Date
