| Au Pair/Mothers Help Details |
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| Name: |
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| Address: |
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| Post code: |
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| Home Number: |
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| Mobile Number: |
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| Email Address: |
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| Work number: |
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| Age: |
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| Date of Birth: |
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| Nationality: |
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| Religion: |
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| Father’s Occupation: |
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| Mother’s Occupation: |
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| Are you already in the UK? |
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| Which visa are you coming on? |
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| Au Pair Package |
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| Type of Package: |
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| Minimum length of stay: |
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| Maximum length of stay: |
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| Where would you like to stay? |
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| Would you like to attend English school? |
Yes No |
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| Do you have a driving licence? |
Yes No |
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| For how long have you been a driver? |
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| Are you prepared to drive in the UK? |
Yes No |
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| Education |
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| Which year did you finish college/University? |
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| Exams passed: |
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| Occupation since finishing college/university: |
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| How good is your English? |
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| Do you speak any other foreign languages? |
Yes No |
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| If yes which ones? |
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| Work & Children |
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| What age would you like to care for? |
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| Do you mind pets? |
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| Would you work with the physically disabled? |
Yes No |
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| Would you work with the mentally disabled? |
Yes No |
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| Can you cook? |
Yes No |
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| Are you prepared to cook? |
Yes No |
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| Are you a vegetarian? |
Yes No |
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| Will you accept a vegetarian family? |
Yes No |
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| Do you have any food allergies? |
Yes No |
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| If so please specify: |
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| Are you familiar with: |
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| Ironing |
Yes No |
| Vacuuming |
Yes No |
| Washing |
Yes No |
| Sewing |
Yes No |
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| Experience |
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| What experience do you have of working with children? |
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| If applying from the UK can you provide references? |
Yes No |
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| If yes please give details of previous employer: |
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| Have you worked as an au pair before? |
Yes No |
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| If yes please state your job responsibilities: |
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| Current occupation |
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| Health |
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| Do you smoke? |
Yes No |
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| If yes do you agree not to smoke in the house? |
Yes No |
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| Do you suffer from any medical conditions? |
Yes No |
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| If yes please give details: |
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| Are you receiving any medical treatment at the moment? |
Yes No |
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| If yes please give details: |
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| Are you pregnant? |
Yes No |
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| General information |
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| Do you have criminal record? |
Yes No |
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| If yes give details: |
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| Do you have friends or family living or working in the UK? |
Yes No |
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| If yes are they local to you? |
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| Their name, address and contact details in case of emergency |
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| How did you hear about us? |
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| How did you find our website? |
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| Are you in contact with other Au pair agencies? |
Yes No |
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| If yes please give details: |
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| Any questions or comments? |
Yes No |
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| If yes please write them here: |
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| DECLARATION |
To the best of my knowledge and belief, the details given on this form are accurate and true and I have not withheld any material facts. I understand that if it is subsequently discovered that any statements are false or misleading, I will be liable to have my application disqualified, or subsequently be liable for disciplinary action. |
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