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Agency  Application
Agreement for Employees


Name:   _____________________________  DOB: ___________ Age:___   SS#:__________________

Home Phone: _________________________  Cell Phone: ____________________________________

Address: ___________________________________________________________________________     

City:______________________________ State: ___________           Zip: ________________________

E-mail Address: ______________________________________________________________________

How did you hear about The Wellington Agency?____________________________________________

How long have you lived at your current address:____________________________________________

List your previous addresses/states that you’ve lived in (over the age of 18):

1. __________________________________________________________________________________  


Please list all states and countries that you have lived in: _______________________________________

Drivers license #: _______________________State issued:          Make/Model of Car: ________________

Plate #________________________________

Insured by: ____________________________

List any moving violations, citations, or accidents on your driving record: ___________________________


High School Attended:____________________   City /State______________  Did you graduate?  ___

College Attended:       _____________________  City /State______________  Did you graduate?  ___

Other :                         _____________________   City/State______________  Did you graduate?  ___


What special skills and training do you have that will make you an outstanding candidate?




Detail computer skills:____________________________________________________________________

What languages do you speak fluently? ______________________________________________________

Have you worked in a formal household? __________________

Have you worked with a large staff before? _________________

Are you comfortable working with a staff? __________________

Do you drive?__________________________________________________________________________

Will you care for pets and do you have experience taking care of animals?_________________________

  List 3 references who are NOT related to you and are NOT  friends,  that you have known for at least 3 years.

            Name                            Relation                                                 Phone





State any organizations that you have been affiliated with and its location.  Please include volunteer work, school clubs, humanitarian efforts and other activities:

1.                                                                                       2.                                                                                         3.


State the name of your physician: ________________________  Phone: _________________________

Date of last physical examination: ________________________

Do you have any medical conditions that could impair your ability/abilities?:

Do you take any prescription medication? ___________ If so what meds? __________

Do you have any allergies? ___________ If so, what are they? ________________________

Do you drink, how often? _____________________________   Do you smoke? __________

Have you ever abused drugs? _________________     Are you willing to be drug tested? ______________

Have you ever been treated for depression, when? _____________________________________________

Have you ever been arrested, explain? ______________________________________________________


Your job requirements:

Desired Salary? _____________ Net//gross:_____________   Are you willing to negotiate? _________

How many hours are you willing to work? ________________________________________________

If no, how long of a commitment are you willing to make? ____________________________________

How far are you willing to commute? ______________________________________________________

What type of coverage do you have for your children?  ________________________________________

Who can we contact in case of an emergency?______________________________________________


Name: _______________________         Relation: ________________        Phone: _______________



                                                        Applicant/ Agency Agreement

I,___________________________ understand that I am now under agreement with The Wellington Agency, LLC and am obligated to report ALL phone calls, interviews and jobs that I have been offered by any of the  agency’s clients, or its client’s friends, neighbors, relatives and associates.  This includes all people I have met who I would not have met if I were not affiliated with the agency.  I agree not to be employed by any of these people unless I have obtained authorization to do so from the agency directly.  I understand that the above mentioned people must pay the appropriate fee to the agency in order to employ me and that it is my responsibility to check with the agency to make sure that the fee has been paid.  I agree not to refer my friends, relatives and/or affiliates to the above mentioned (agency clients, friends,  and family)  associates ,  for employment purposes.  I agree to pay the agency $10,000  and any legal fee’s incurred be the agency if I violate the terms of this agreement.

Print name: ____________________ Signed: __________________ Date: __________

I, have been verbally instructed and I agree to the terms of this employment application contract.  

Initial:_______________    Date: ___________


New York, London: (917) 546-6809
Palm Beach, Miami: (561) 713-2663
Los Angeles, Palos Verdes: (310) 697-7191
Boston: (617) 275-8190

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