GALIAU-PAIR Galiau-Pair, La 1ª

GALIAU-PAIR Galiau-pair, la 1ª

C/ Hórreo 19 Local 9 (Galerías Viacambre) agencia fundada en Galicia en 1991

15702 SANTIAGO DE COMPOSTELA

Tel./Fax. 981-570599

E-mail:

APPLICATION FOR AN AU-PAIR POST IN EUROPE

Please complete this form in the language of the country you will stay in, if possible.

YOUR STAY IN EUROPE

Starting date: / How many months can you stay:
Minimum: / Maximum:
Which part of the country do you prefer?
1st Choice: / 2nd Choice:
3rd Choice:
Will you accept to stay in:
A town: / A village: / The country / A farm:

PERSONAL DETAILS

Full name:
Address:
Telephone number: / Mobil : / e-mail:
Marital status: / Single: Yes
Family address (if different):
Age: / Date of birth:
Place of birth: / Nationality:
Do you smoke? / Yes No / How many a day? / Can you stop smoking?
Do you drive? / Yes No / Since when? / Will you driven in Europe? / Yes No
What is your profession?

LANGUAGE ABILITIES:

Very good: / Good: / Slight: / None:
English / French: / German: / Italian: / Others:

FAMILY DETAILS

Occupation of father: / Mother:
Ages of brothers: / Sisters:

HEALTH (Please supply a medical certificate to confirm these points)

Have you good health? / If no-why?
Do you have any allergies?
Have you been treaded in hospital recently? Please Details:
Have you had any illnesses over the past 5 years? Please details:
Have you been treated for mental or psychological problems? Please details:

GENERAL DETAILS

Do you like children? / Yes No / Can you look after: / Yes No
Babies:
Yes No / Toddlers:
Yes No / School children:
Yes No / Teenagers:
Yes No
What experience have you had with children?
Do you have any child care qualifications?:
Do you have practical experience with housework?:
Are you prepared to help with the following:
Simple cooking: / Yes
No / Ironing: / Yes
No / Dusting: / Yes
No / Washing: / Yes
No
Hovering: / Yes
No / Childminding: / Yes
No / Babysitting: / Yes
No
Would you agree to be with a single member of a family?

GENERAL DETAILS (Continued)

Do you like animals?
What are your hobbies and interests?
Please state any further that you would like us to know:
Have you ever been convicted of an offence Served a Sentence, Suspended Sentence, or been held in Custody, prison or any other detention Centre: YES / NO
IF YES PLEASE DETAILS:
I DECLARE
I confirm that to the best of my knowledge the above information is true and I have understood the conditions as supplied by GALIAU-PAIR
Signed Date: