A. Personal Details
First Name		Family Name
Permanent Address		Telephone
Name, Address and Phone Number of parents or next of kid (if different from above):
Date and Place of Birth:		Nationality
Your profession		Parent's professions
Ages of Brothers and Sisters		Religion
Do you mind being placed in a family of different religion?		Do you hold a current driving licence?
Would you be willing to drive in Ireland if required?

B. Education
Secondary School		How many years did you study English at the above?
		What was your main area of study at the above?
Third Level Institution
How many years did you study English at the above?       Give the particulars of English Language       Schools attended (Name of Schools;       Years attended; frecuency of classes)
Give details of Public Exams passed in English (Title; Grade; Date)
What level do yo think your spoken English is?
Advanced Upper-Intermediate Intermediate Basic
What other languages do you speak? (give levels)

C. Health
Heigth Weight Smoker?
Give a list of any serious illnesses you have suffered
Give details of any allergies you have
Do you suffer from any of the following? If so, give details: diabetes; asthma; heart complints; nervous disorders.
Are you, at present, undergoing a course medication? If so, give details.
What is your general state of health?

 

 

 

 

 

 

D. Work Experience (Employer's references required)
If you have been employed looking after children, please give the following information:
• Name and Address of Employer (s)
• Dates worked
• Title of job
• Ages of children
• Duties (be specific)
If you have had other employment, please give name and address of employer, dates worked and title of job.
Give details of your experience in the following:
• Ironing
• Hovering and Cleaning
• Cooking
• Other housework
Is there any group you do not wish to work with? If so, specify.

E. General
Please list hobbies in order of preference
What sports, if any, are you currently practising?
State why you wish to be an Au-Pair
What is the earliest date you can come?
Who long you will be able to work as an Au-Pair?