Name ________________________
Address
_____________________________

Telephone
Home _______________
Work ________________
Business No.
____________________

Child care         yes     no	Number of children _______	Ages of children _______
Elderly care      yes     no	Care for disability             yes      no

Care responsibilities/duties (describe)
_______________________________________________________________
_______________________________________________________________

Housekeeping responsibilities/duties      yes     no

Describe _______________________________________________________
_______________________________________________________________
_______________________________________________________________

Will employee be required to provide pet care?      yes     no

Additional responsibilities      yes     no

Description of the house and household (number of rooms, household members, etc.)
________________________________________________________________
________________________________________________________________
________________________________________________________________

Wages and working conditions must reflect provincial employment standards and prevailing wage rates.

The employer agrees to provide the employee with information regarding wages and types and approximate amounts of deductions from pay.

Weeks of vacation with pay _____/yr       Paid general holidays _______________

Other leave ___________________________ Days of paid sick leave _____/yr

Cost of room and board $_________       To be paid _____ weekly _____ monthly

Accommodation: Furnished Private Room    yes     no

Locked                 yes     no

Private Bath         yes     no

Medical coverage _______________         Other benefits _____________________

Airfare included    yes     no         Details _______________________________

  Income tax deductions will be taken at source

  Contributions will be made by employer to Canada/Quebec Pension Plan and to Employment Insurance

Duration of employment ______________________________________________