Au Pair Agency Cefelin - Application Form

Please note, that by filling out the form you do not yet have any obligations towards our company!

your contact details (* = mandatory field)
gendermalefemale
* surname
* first names
date of birth: (DD.MM.YYYY)
Nationality:
place of birth:
city:
country:
current address:
street:
postcode:
city:
country:
* phone. no:
mobile phone:
* e-mail:
nearest relative:
surname:
first name:
street:
city:
country:
father's occupation:
mother's occupation:
ages brothers & sisters:
religion:
education, including examinations passed:
work experience - please give dates:
present job & dates:
what languages do you speak? what level?
language 1:
level:basic 2 3 4 native
language 2:
level:basic 2 3 4 native
language 3:
level:basic 2 3 4 native
do you wish to attend language classes?yes no
when can you start?
how long can you stay?
give a brief summary of your experience, indicating the nature of care provided, the ages of children and for how long:
childcare experience and training:
please give details about the number of children you would like to take care of and the preferred ages of the children:
childrenīs ages:0-2 2-5 5-10 older 10
number of children preferred:1 2 3 4 more than 4
domestic experience:
washing up: (do you have experience?)yes no
are you willing to do?yes no
ironing: (do you have experience?)yes no
are you willing to do?yes no
cooking: (do you have experience?)yes no
are you willing to do?yes no
vacuuming: (do you have experience?)yes no
are you willing to do?yes no
dusting: (do you have experience?)yes no
are you willing to do?yes no
laundry: (do you have experience?)yes no
are you willing to do?yes no
driving:
do you have a driving licence?yes no
when did you pass your test?
are you willing to drive abroad?yesno
do you drive regularly?yesno
details of any accidents:
do you have any first aid training?
if yes, which?
can you swim?yes no
can you play a musical instrument?yes no
are you willing to live with pets?yes no
what are your interests?
sports, hobbies, music etc.
why do you want to be an au pair?
what are your future plans when
your au-pair stay is ended?
where do you want to live?:
large town:
suburb:
small town / village:
countryside:
no preference:
Would you accept a single parent family?
mother only:yes no
father only:yes no
would you work with a disabled
child?		yes no
do you have any experience? (disabled child)yes no
which experiences do you have
with a disabled child?
have you been abroad
without your family?		yes no
if yes (please give details)
have you ever been convicted
of a criminal offence?		yes no
health declaration:
are you undergoing any treatment/check up due to injury, handicap or physical disorder?yes no
if yes (please give details)
do you suffer from any allergies?yes no
if yes (please give details)
do you use any medication
regularly?		yes no
if yes (please give details)
do you suffer from any kind
of eating disorder?		yesno
if yes (please give details)
do you follow any special diet?yesno
if yes (please give details)
do you smoke?yes no
if yes, how many per day?
will you promise not to smoke in
the house or in front of the children?		yes no
please ensure you have read and understood the information provided by the agency for au pair applicants and agree to follow the guidelines.
yesno
please type in the secure code: please be aware of upper and lower case
SECURE CODE:
secure code
 
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