| PERSONAL DETAILS: |
| Your Name: |
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| Email Address: |
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| Address (Line 1): |
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| Address (Line 2): |
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| Town: |
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| County: |
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| Postcode: |
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| Country: |
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| Telephone (Home): |
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| Telephone (Mobile): |
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| Telephone (Work): |
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| Nationality: |
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| Date of Birth: |
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| Place & Country of Birth: |
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| Age: |
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| Height: |
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| Weight: |
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| Sex: |
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| Hair Colour: |
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| Eye Colour: |
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| Earliest date available: |
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| Latest date available: |
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| Length of stay required: |
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| Preferred Location: |
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| Do you have a driving licence? |
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| Are you willing to drive in the U.K? |
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| Date driving test passed: |
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| EDUCATION: |
| Level of education: |
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| Languages spoken: |
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| Level of English: |
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| Present Occupation: |
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| Employer: |
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EXPERIENCE:
(Childcare, babysitting, housekeeping, medical, teaching, etc.) |
| Job #1 |
| Dates: |
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| Name & Address of Employer: |
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| Telephone: |
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| Responsibilities: |
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| Job #2 |
| Dates: |
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| Name & Address of Employer: |
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| Telephone: |
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| Responsibilities: |
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| HOUSEWORK EXPERIENCE: |
| Are you willing to do housework? |
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| Vacuuming experience: |
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| Dusting experience: |
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| Ironing experience: |
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| Tidying experience: |
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| Cooking experience: |
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OTHER REFERENCES:
(Work, school, etc.) |
| Referee #1 |
| Name: |
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| Telephone: |
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| Relationship: |
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| Referee #2 |
| Name: |
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| Telephone: |
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| Relationship: |
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| FAMILY BACKGROUND: |
| Father's name & occupation: |
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| Mother's name & occupation: |
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| Address & Telephone: |
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| How many brothers/sisters do you have? How old are they? |
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| Religion? Do you regularly attend religious services? |
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| Are your parents supporting your decision to come to the UK? |
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| AGE GROUP EXPERIENCE: |
| Newborn: |
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| 9 - 24 months: |
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| 2 - 5 years: |
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| 5 - 10 years: |
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| Older than 10: |
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| Special Needs: |
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| Age group preference: |
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Family Preference:
We will try to place you with a family suitable to your personality, but indicate if you do not wish to be placed with any of the following families |
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| ABOUT YOU: |
| What interests do you have? |
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| Do you swim, have a background in art, music or dance or have other skills that may relate to childrens' activities? |
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| Do you smoke? |
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| Have you ever taken illegal drugs? |
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| Do you get homesick? |
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| Have you ever lived away from home? |
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| Have you ever lived out of country? |
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| Do you have a criminal record? |
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| Have you ever been married? |
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| Do you currently have a steady relationship? |
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| Do you have children of your own? |
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| Do you have any financial commitments? |
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| Do you have any physical or mental limitation? |
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| Do you have any medical conditions requiring treatment? |
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| Do you have any allergies? |
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| Do you have any dietary restrictions? |
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| If yes, please give details: |
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| Why do you want to be an Au Pair? |
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| What are your plans after you have been an Au Pair? |
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| How did you hear of us? |
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