*First Name:
*Last Name:
Spouse first name:
Spouse last name:
*Postal Code:
*Home Phone:
*Business Phone:
Business Fax:
Mobile Phone:
Best time to reach you:

Type of Nanny/Caregiver and your needs:

*What type of nanny or caregiver are you seeking:
Type Gender(s) Age(s)
Elderly Care
Disabled Care
Child Care
Please indicate the main duties of the caregiver:
Housekeeping Responsibilities, if any exist:
*Do you have a private bedroom for the nanny/caregiver:
Yes     No
Will your caregiver be required to provide pet care:
Yes     No
Description of House & Household (type of house, # rooms, bathrooms, and # of household members, etc.):
Private furnished accommodations provided for the Caregiver?:
Yes     No
Describe any special features of the nanny/caregivers living area (i.e. a separate apartment, separate wing, basement room, attic room, kitchen, sitting room, etc.):
Please share any other comments you think would be helpful to us:
Have you previously employed a foreign Live-in Caregiver?:
Yes     No

General Terms & Conditions... DISCLAIMERS

I acknowledge that I have read the Terms, Conditions and Disclaimers as provided on the CanadaEliteCare website, and agree to the terms and conditions and acknowledge the disclaimers provided.
I agree.