Au Pair Online Application Form
CONTACT DETAILS
* Surname
* First Name
* Address
Town/City
Region
Country
Postcode
* Phone (Home)
Mobile
* Email Please re-enter
Are you in the UK already?	Yes No
PERSONAL DETAILS
* Nationality:	Please select AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamasBahrainBaker IslandBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilVirgin Islands, BritishBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocosColombiaComorosCongoCook IslandsCoral Sea IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland IslandsFaroe IslandsFijiFinlandFrancePolynesia, French GabonGambiaGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuyanaHaitiHeard Island and McDonaldHondurasHong KongHowland IslandHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJan Mayen IslandsJapanJarvis IslandJerseyJohnston AtollJordanJuan de Nova IslandKazakstanKenyaKingman ReefKiribatiKoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNavassa IsLandNepalNetherlandsAntilles, DutchNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalmyra AtollPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and The GrenadinesSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSpratly IslandsSri LankaSudanSurinameSvalbordSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin IslandsWake IslandWallis and FutunaWestern SaharaWestern SamoaYemenYugoslaviaZaireZambiaZimbabwe
* Date of Birth:
Sex:	female male
Passport number:
Date of Expiry
Do you have a Visa?	Yes No     (if applicable)
Date of Expiry (if yes)
How important is religion?	Very Average Not important
If very, how often do you pray?
Do you have any marks, visible tattoos or body piercing? Please describe.	Yes No
Have you a police record?	Yes No
Father's profession.
Mother's profession.
BACKGROUND INFORMATION
Occupation
How many years have you studied English?
What is your level of English? Please be truthful - the family will find out soon enough!	Basic Fair Good Fluent
What languages do you speak? Please give details.
Do you wish to attend English Classes?	Yes No
* What is the earliest you would like to start?
How long would you like to stay?	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 months (minimum stay 3 months)
Have you been an Au Pair before? Please tell us when, where and for how long?	Yes No
Have you had any childcare experiences. Please describe FULLY giving type of care and ages of children etc.	Yes No
Why do you want to be an au pair? Please tell us in as many words as possible - this is what the family like to read.
What type of Au Pair would you like to be?	Do not mind Au Pair (25 hours) Au Pair Plus (35 hours) Mother's Help (variable)
Do you have any health problems? Please describe.	Yes No
Do you have any allergies? Please describe.	Yes No
Do you require a special diet? Please describe.	Yes No
Do you smoke?	Yes No
Can you swim?	Yes No
What sports do you play? Please describe fully.
Do you like pets? Please describe fully.
Please describe your interests fully, ie drawing, music, theatre.
Can you drive? If yes, would you drive in the UK after some lessons?	Yes No
If you drive, when did you start driving regularly?
Would you accept to live with a family with:	a single Mother?	Yes No
	a single Father?	Yes No
	a different ethnic origin?	Yes No
	elderly persons?	Yes No
	a different religion?	Yes No
	without children?	Yes No
Are you willing to do:	Light Housework (cooking, washing, ironing etc)
Are you capable of looking after: Please check on/off as appropriate.	0-1 years 1-3 years 3-5 years 5-15 years Disabled children
Please give us any special request you may have.
REFERENCES We require references. Please advise the name and address and telephone number of your referees for both a  childcare and character reference.
Your childcare reference. Name, address, telephone number, email and/or fax number
Your character reference. Name, address, telephone number, email and/or fax number
I HAVE READ AND FULLY UNDERSTOOD EVERY QUESTION IN THE ABOVE APPLICATION FORM AND I HAVE ANSWERED IN FULL AND TRUTHFULLY.
* I have read and understood, and agree to the terms and condition of business of A Class Au Pairs.
Date:		Agency   (Agents only to complete.)