Housekeeper Questionnaire

Live In Full Time Live Out Full TimePermanent Part TimeShort Term
Name 1: BUS Email
Name 2: BUS Email
Home Address: H.Tel
City Province Postal Code
Closest Main Intersection: On Public Transit?:YesNoLimited
Persons living in home:
Name Adult/Child/Senior School
Social interests, Activities, Medical problems :
Start date preferred: latest by:
Do you prefer a non smoker?: YesNo
Will you accept a social smoker?: YesNoIf they smoke in restricted area
Preferred Age: Other Preferences:
Driver's licence ? YesNo Car available? Daytime YesNo
Own car required? YesNo Required to drive children?Mileage paid?
Work Schedule:
MonTueWedThrFriSatSun Hours: Shift work:
Start/Finish Time Wages offered:
Benefits: Paid sick days?
Duties required of the employer:
House Keeping
Daily TidyingDustingVacuumingMaking BedsSponge Mop/Wash floorsClean kitchen & bathroomsCleaning ClosetsMeal PlanningLoad/Unload DishwasherCleaning BedroomsWashing Windows(inside)Assisting with Entertaining
FamilyChildren's OnlyHousehold Bed/Bath LinenIroning
Meal Prep
Running ErrandsGrocery ShoppingOrganizing/Sorting DrawersOccasional other odd jobs
Pet Care: Dog(s)Cat(s)Other
Household Appliances
Oven/StoveMicrowaveDishwasherTrash CompactorWashing MachineDryerVacuum CleanerWall Vacuum
Other comments regarding the position of the potential employee are most welcome:
Are you a previous client? If so, when?
Whom shall we thank for referring our services?:

Both Employers and Workers have rights and responsibilities under the provincial Employment Standards Act. All placements made through Trafalgar Personnel Limited follow the guidelines of this legislation and all guarantees are based on the premise that these regulations have been followed. Although there must be room for flexibility in In-Home Care placements, only those whose Job Offers meet these guidelines will be accepted as potential clients by Trafalgar Personnel Limited.

We expect both Employers and their Caregivers to treat each other fairly and with respect, as well as to maintain open communication lines so that they can work together in finding solutions to any problems that may arise. We are here to provide guidance and support, whenever needed, throughout the entire placement. We also promise to provide a service of unparalleled excellence !

Questionnaires and ISF Registration Fees paid are valid for a maximum 6 month period.

SERVICES AND FEES : (Fee Effective Sept 1, 2013) – to register and begin a search

(Non-refundable & valid for a maximum of 6 months unless there have been less than 3 possible candidates for interview)

INITIAL SEARCH FEE (ISF) to register and begin a search: $100..00 PLUS HST

No Initial Search Fee is payable in advance for Part Time Positions of less than 20 hours per week. If we are able to find suitable candidates for interview, the ISF will be payable upon placement OR prior of arrangement of an interview for a third possible candidate, whichever comes first.

PLACEMENT FEES (Effective September 1, 2013):

(Payable IF you choose one of our candidates and make them a formal Job Offer )

(Canadians, Permanent Residents & Open Permits)
Full Service Contract 4 Weeks Gross Wages (for Child &Elder Care)* to a Maximum $2,600.00 + HST
HOUSE MANAGERS Full Service Contract 4 Weeks Gross Wages * to a Maximum $3,000.00 + HST

(Free replacement if employment is terminated within the first 12 weeks, with a prorated guarantee from 13thweek to end of 9th month)

Should you choose to directly hire any applicant introduced to you through Trafalgar Personnel Limited within 12 months of that introduction, all placement fees will be due and payable as per our current Agency Policies & Fee Schedule.

All Fees are valid for 15 days and subject to change. * NB. We do NOT accept Credit or Debit Card payments.

Should you wish to register with Trafalgar Personnel Limited and have us begin a search on your behalf, please check the box indicating how you will be forwarding your ISF Registration fee.
I will forward an E-Transfer payment of $113.00 ( inclusive of HST) on-lineI will mail a cheque for the initial search fee of $113.00 (inclusive of HST)I will drop off a cheque for the initial search fee of $113.00 (inclusive of HST) within the next 3 days,As I am looking for a Part Time caregiver 20 hours per week or less, I will forward payment of the Initial Search Fee if a suitable candidate is found , OR prior to interviewing a third candidate through the agency.

* We do not accept credit or debit card payments.

Please check here to indicate that all the information you submitted is correct and that you have read and agree with the Agency Policies and Fee Schedule

Signature Date

Please Note: The Agency reserves the right to refuse any order that it feels is not fair or reasonable, does not meet Employment Standard guidelines, and / or does not meet the standards of the Agency. If an order is refused, the initial search fee will be returned immediately.

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News/Upcoming Events


Childcare $11.54/hr.

Eldercare $13.91/hr.

Wages for caregivers on a work permit are now based on


for the region of the province in which they work.


Check : ESDC Website

At Camp CanAqua in Halliburton
June 16 – 18, 2017.

Au Pairs on Cultural Exchange placements are another option to meet your childcare needs!