Your Contact Information

	First name
	Last name
	Company
	E-mail address
	Telephone
	Facsimile
	Street address (1)
	Street address (2)
	City
	Province
	Country
	Postal code

Type of Caregiver Required

	What type of caregiver are you seeking?
	Child Geriatric (elderly) Special Needs, Disabled or Convalescence

	If you require child care, how many children do you have?
	How old are your children?
	Do you have any children or elderly with special needs?
	If yes, please explain:

	When do you need your caregiver to start work? (Please allow at least 6 months for processing by HRDC & Immigration Canada)
	Year: Month:  Day:

Your Typical Schedule

	How many hours per week will you need a caregiver?
	When will his/her hours of work be?
	When will his/her days off be?
	Will you require shiftwork?	Yes No

Travel

	Do you travel frequently?	Yes No
	When you travel, do you plan to take the caregiver?	Yes No

Duties

	What duties will you require from your live-in caregiver?
	Meal Preparation  Cleaning  Transportation  Laundry  Pet Care
	Are there any specific duties, which we have not listed above?	Yes No

If yes, please explain:

Accommodations, etc.

	What type of accommodation do you have for your live-in caregiver?
	Separate suite with bathroom  Separate suite with shared bathroom

	Will your live-in caregiver be required to drive?	Yes No
	Will you be providing a vehicle for her/him to use?	Yes No

	What are your special interests?
	Sports  Music  Arts  Languages  Hobbies

Other Information

What type of education/background would you prefer for your live-in caregiver?