PERSONAL DETAILS
First name
Last name
Date of birth (DD/MM/YYYY)
Sex	MaleFemale
Place of birth
Nationality
ID serial number
Height (cm)
Weight (kg)
Religion
Are you practicing?	YesNoN\A
Street
City
Postcode
Country
Private phone (with country code)
Mobile phone
e-mail address
OTHER PERSONAL DETAILS
Do you have a full clean driving licence?	YesNo
If yes, would you drive the car of the host family?	YesNo
Are you a confident driver?	YesNo
Date of issue of licence (DD/MM/YYYY)
Do you smoke?	YesNo
Are you prepared to give up smoking in the house?	YesNo
Do you like pets?	YesNo
Can you swim?	YesNo
Can you ride a horse?	YesNo
Can you ride a bicycle?	YesNo
Do you practice any sports?	YesNo
Which ones?
Do you play a musical instrument?	YesNo
Which ones?
Are you a vegetarian or have any dietary restriction?	YesNo
Do you have any physical disabilities / allergies?	YesNo
Which ones?
Have you ever suffered from any mental diseases?	YesNo
Which ones?
Do you have a criminal record?	YesNo
DETAILS ON MEMBERS OF YOUR FAMILY
Parents Mother Father Occupation Age Siblings Sisters Brothers Number Own children Daughters Sons Number

EDUCATIONAL & PROFESSIONAL EXPERIENCES, VISITS ABROAD, HOBBIES
Education – name of school, gained education	From (MM/YY)	To (MM/YY)
Training, courses etc. – name of the course, qualification gained	From (MM/YY)	To (MM/YY)

Professional experience
From (MM/YY)	To (MM/YY)	Name of the company	Position held
Interests/hobbies
Current status  studentgraduateunemployedemployeeself-employedretired
Former visits abroad (country, purpose)
English language abilities  very goodgoodfairaveragebasicnone
How long have you learnt the English language? (Months)
Where did you learn the English language?
Other languages?

EXPERIENCE IN HOUSEWORK, CHILDCARE, CARING FOR ELDERLEY / DISABLED PEOPLE & OTHER ABILITIES
Do you have experience in...?
Cleaning / dusting / vacuuming	goodfairpoornone
Ironing	goodfairpoornone
Cooking	goodfairpoornone
Baking	goodfairpoornone
Laundry	goodfairpoornone
Washing up	goodfairpoornone
Cleaning windows	goodfairpoornone
Making beds	goodfairpoornone
Gardening	goodfairpoornone
Looking after pets	goodfairpoornone
Looking after the elderly	goodfairpoornone
Bathing elderly people	goodfairpoornone
Getting elderly people dressed	goodfairpoornone
Looking after disabled people	goodfairpoornone
Bathing the disabled	goodfairpoornone
Getting disabled people dressed	goodfairpoornone
Looking after children	goodfairpoornone
Keeping children occupied	goodfairpoornone
Bathing children	goodfairpoornone
Getting children dressed	goodfairpoornone
Supervising homework	goodfairpoornone
Caring for babies (under 2 years of age)	goodfairpoornone
Where did you gain this experience?
Do you have any other abilities/skills?    YesNo
Please give details:

PREFERENCES
Age group of children you wish to look after
0-6 months	FavouriteLess favouriteNot at all
6-12 months	FavouriteLess favouriteNot at all
1-3 years	FavouriteLess favouriteNot at all
7-10 years	FavouriteLess favouriteNot at all
11 – more years	FavouriteLess favouriteNot at all
How many children
Would you like to look after elderly people?  YesNo
Would you look after disabled people?  YesNo
If yes:  mentally handicappedphysically disabled
Would you like to work as a housekeeper?  YesNo
Would you work for a single parent / person?  YesNo
If yes:  single mother / ladysingle father / man
DETAILS OF YOUR STAY
Preferred area / alternative
Preferred type	citytowncountrydon’t mind
Length of stay (Months)
When could you start? (DD/MM/YYYY)
Proposed day of return (DD/MM/YYYY)
Do you have a contact person in the area which you wish to visit?   YesNo
Can you accept a family of different cultural/ethnic backgrounds?   YesNo
Did you apply in other agency?    YesNo
Have you been a carer / a housekeeper / an au-pair before?   YesNo
If yes in which country   how long (Months)
REFERENCES
Reference 1:
Name:
Relationship to applicant:
How long known applicant (Months)
Telephone number:
Address:
Reference 2:
Name:
Relationship to applicant:
How long known applicant (Months)
Telephone number:
Address: