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    Salutation First Name Last Name Secondary Contact Name Email Home Street Home City Home State/Province Home Country Home Postal Code Mailing Address (if different from home) Occupation Phone Number Mobile Phone Number Fax Date of Birth email-opt-out fax-opt-out do-not-call List Name and DOB of Those Requiring Care What Are You Interested in Discussing? General pricing informationHow we find, screen and match nannies with familiesProfiles of nannies that are currently availableDo you have any specific questions for us? Who Is Now Responsible for Their Care? Concerns, Diet, Allergies, Disabilities Have You Previously Hired a Nanny? Nanny Duties/Criteria Languages Spoken in Home (Eng/Fr/Other) Medical Information Other Persons Living in Home Please Describe Any Pets in the Home Revenue Canada Business Number Type of Accommodation Provided When Is Help Required? Work Day Start Time Work Day End Time Who Did You Find Helpful at Preferred? How Did You Hear About Preferred Personnel?
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