IMPORTANT: This application form must be printed out and completed in English using BLOCK CAPITALS.

Au Pair applicants are expected to answer questions below carefully and in all sincerity as failure to do
so, terminates job offer as well as documentation.

Name: ___________________________________________________________________________

Nationality: ______________________ Date of birth: __________________ Sex: ______________

Marital Status: ___________________ Current Address: __________________________________

Do you smoke? YES NO

Have you been to UK before? YES NO

Will you like to be registered for English classes? YES NO MAYBE

Can you swim? YES NO

In the event of Au pair application, the Au pair will be required to prove that he/she is capable to meet
the necessary placement financial insurance fee for Au pair/ Care giver financial status endorsement.

I will be able to meet up with the necessary financial requirements in the course of my application.

Disclaimer: Information as found on this form is not falsified but original and verifiable, as I will be
held responsible if found wanting.

Surname: ___________________First Name: __________________ Other Names: _________________

Mobile Number: __________________________ Employers Name: _____________________________

Intended Resumption Date: _________________ Length of Stay: ______________________________

Selected Next of Kin: _________________________ Next of Kin Phone: ________________________

Sign: _________________________ Date: _________________Time:____________________