We would like to have a: Female

  Male au-pair through your agency

FATHER

First name:

Age: Profession:

Last name:

MOTHER

First name:

Age: Profession:

Last name:

Address:  

Phone:            

City:       

Fax:                

State/Zip:

Phone at work:

Country:  

Cell phone:     

E-mail:   

We live in:  House  Apartment

Number of rooms:

Will the au-pair have an own room Yes No

There are members in our family

We have  children

Age:           Attends school               Yes        No

Age:           Attends school               Yes        No

Age:           Attends school               Yes        No

Age:           Attends school               Yes        No

Age:           Attends school               Yes        No

Age:           Attends school               Yes        No

Does your family travel often        Yes  No

If Yes, will your au-pair travel with you:     Yes  No

Are there smokers in your family:  Yes  No

Does your family have pets:          Yes  No

If Yes, what pets

Did your family have an au-pair before:      Yes   No

If Yes, from what country:

What year:   How long time: months

How many days would your au-pair work during each week:

How many hours would your au-pair work each day:          

Tell us something about the duties you expect your au-pair to peform during the days with your children:

Is there any housework included:   Yes No

If Yes, please list duties:

What will you pay your au-pair each week:  each month:

Will you pay for the transfer trip:  Yes No

If Yes, how could the transfer trip be arranged             (could you for instance meet the au-pair at the airport):

We would prefer an au-pair who is years old

We would prefer an au-pair who is able to speak:

Other language skills required:                             

The language we speak at home is:                       

Will your au-pair be able to attend a language class at your expense: Yes No

Will it be necessary for your au-pair to have a driving license:           Yes No

Will your au-pair have access to a car:                                            Yes No

We need our au-pair for:   months starting:

Give your future au-pair a short description of your family: