Caretakers application form: 

Date: 
Social Security #: 
Applicants Names: 
Present Address, City,State: 
Phone#: 
Are you Employed now? 
Date You Can Start:  
Describe your capabilities:  
Activities other than religious(Civic, Athletic, Hobbies, Interests, etc.)
If yes, may we contact?   
Grammar School


High School


College


Trade or Business 
    School

Name and Location  
Did you
Graduate? 
Year Completed
19xx or 20xx

Education  
Employment 
From:
To::  
Name and Address 
Salary
Position
Reason for Leaving
From:
To::  
From:
To::  
From:
To::  
References  Give below the names of three persons not related to you that you have known at least one year. 
                                                                                                                                                                                     Years 
Name                                                 City/State                                   Phone#                How Known                    Acquainted         
Physical Record: Do you have any physical condition which may limit your ability to perform the responsibilities? 
                                     This question is voluntary and any answers will be kept confidential.  
Do you own a boat? 
If yes, what type?   
E-mail Address:
Salary Desired?
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No