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Please note compulsory fields are marked with an asterisk (*).
A - PERSONAL AND CONTACT INFORMATION
Full Name
 
Nationality    
   
Address    
 
City/Town    
Postal Code    
   
Telephone (Home)   Telephone (Work)          
           
Mobile   Fax          
           
E-mail Address
Partner or Next of Kin Name
Partner or Next of Kin Contact No.
B - ACCOMMODATION AND PREFERENCES
Type of Accommodation (Please Tick)

 House Flat

Maisonette          
Does family have pets?
How far is family from London ?
Where does family stay? *
Has family had an Au-pair before
If Yes, give the date and duration
Does family prefer

Male

Female

Do Not Mind          
Does family prefer Non-smoker? *  
 
 
C - AU-PAIR AND FAMILIES INFORMATION
Please tick any of the au-pair duties that apply
Getting children ready for school Cooking children light meals
Driving children to school Family laundry
Walking children to school Children’s ironing
Light house work Others (Please specify)  
If Others (Please specify)  
 
Children details (Including Name, Age and Sex)  
 
Does any of the children suffer an allergy? If Yes, please specify
Will Au Pair be required to work weekends? Will family meet Au Pair from Station/Airport
Will  arrangement be made for the collection of Au Pair? * Will family need agency to meet and deliver Au Pair ?
Please give full details of Au Pair bedroom  
 
Will the Au Pair require the use of a car?  
 
If Yes, for which purpose? Please choose below.  

Work Only

Work and English classes  

Work and leisure

Leisure only  
What other form of transportation will be available locally to the Au Pair?

Train

Bus

Others    
If Others Please Specify  
 
How far is the local College that teaches English Specify Au Pair working hours
Specify Au Pair free time How much will family pay Au Pair per week (Rate in Pounds)
When does family want Au Pair to start work Specify preferred duration of stay
Family reference Name
 
Telephone  
 
Other sources of information