AU-PAIR

MEDICAL HEALTH CERTIFICATE

First name _______________________Surname___________________________

Street_____________________________________________________________

Postal code ____________ City________________________________________

Telephone no _______________________________________________________

Date of birth ___________________Citizen of _____________________________

Comments___________________________________________________________ ___________________________________________________________________ ___________________________________________________________________  ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

I hereby certify that, to the best of my knowledge, the above applicant is completely healthy,both physically and mentally.

Signature of Physician _________________Date of examination_____________

Name of Physician___________________________________________________

Physician`s Stamp