Surname:
First Name:
Address:
Address2:
City:
Post Code:
Country: (if
your country is not on
Andorra
Austria
Belgium
Bosnia
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Germany
Greece
Greenland
Hungary
Iceland
Ireland
Italy
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovak Republic
Slovenia
Sweden
Switzerland
Turkey
United Kingdom
Telephone:
Mobile:
Fax Number:
E-mail Address:
Personal details
Date
of Birth:
Sex:
Male
Female
Nationality:
Religion:
Marital
Status:
Single
Married
Separated
Divorced
Widowed
Father's
Occupation:
Mother's
Occupation:
Number
of brothers & ages:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Number
of sisters & ages:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
I'd
like to be: Au Pair
Yes
No
Yes
No
Date Available:
Minimum
length of stay (in months):
Maximum
length of stay:
I
prefer to be in:
A town
Countryside
No preference
Education & experience
Education and Diplomas:
Present occupation:
Knowledge of English:
Poor
Moderate
Fluent
Number of years spoken:
Other languages spoken:
What experience do you
Date of leaving school
Date of leaving college / university
Occupation/s since leaving
Preferences
I am ready to help with
0-1 years
Yes
No
1-12 years
Yes
No
13+ years
Yes
No
I am ready to stay with
Adults only
Yes
No
A single mother
Yes
No
A single father
Yes
No
Of a different religion
Yes
No
I am wiling to help with a physically disabled child:
Yes
No
I am willing to help with a mentally disabled child:
Yes
No
I will accept a family
with a cat:
Yes
No
I will accept a family
with a dog:
Yes
No
More
details
Who Reffered You?
Are you allergic to anything?
Are you under medical
Are you vegetarian?
Yes
No
Are you prepared to
Yes
No
Will you accept a family
Yes
No
Are there any foods
Do you smoke?
Yes
No
If yes, how many cigarettes
0
1
2
3
4
5
5+
Will you promise not
to
Yes
No
Do you have a driving
licence?
Yes
No
Date driving licence
obtained:
Are prepared to drive
in the UK?
Yes
No
