Ltr

SC Lion Trade SRL

Application checklist:
 Completed application form (this form).
 Your criminal record transcript.
 Medical record verification form.
 Copies of your latest school diplomas
 Copy of your driver’s license.
 Copy of your passport (the one page with personal info only).
 One passport photo.

NOTE: Please note that we cannot return any of your application documents, including photographs or
references at any time. Therefore, please keep a copy.

Tips for filling out the application:

•Type or write neatly with black ink.

•Write your name at the top of all pages and attachments.
•Understand what you are signing.

Criminal record: Contact your local police office to order a transcript/printout/certificate of your criminal
record.

Medical record form: Contact an accredited doctor form the attached list to have the medical form filled out.
 Au Pair information

I apply for Country: BELGIUM

Requested starting date:

Length of stay:

Personal information

Surname

Christian names as in passport

Address

Zipcode & Town

Country

Telephone home

Mobile

E-mail address

SKYPE

Date of birth

Place of birth

Marital Status

Passport n°

Date & place issued

Expiration date

Nationality

dd au pair agency – www.ddutch.eu – info@ddutch.eu - +32 472 74 56 16

Availability

Earliest departure date

Latest departure date

Departure airport

Nearest Embassy (city)

Contact Information

Telephone n° & best time to call

Skype best time to contact

Mobile phone best time to call

How often do you check your e-mail

Emergency contact

Name & relationship

Home phone

Work phone

Mobile phone

Address

Driving experience

Do you have a driving license

dd au pair agency – www.ddutch.eu – info@ddutch.eu - +32 472 74 56 16

 Yes No

How long have you had your license

Do you own your own car

How often do you drive per week

How do you rate your driving skills

Excellent/good/fair/poor

Diploma

Do you have a High School Diploma? Yes No

Do you have a Post-Secondary School Yes No
Diploma?

Are you still studying at the moment? Yes No

Skills, interests and hobbies

Can you ride the bicycle? Yes No

Can you swim? Yes No

Do you like animals? Yes No

Can you cook? Yes No

Name:

I confirm that all above information and all information I give on the application documents for the work permit is
true, correct and complete.

dd au pair agency – www.ddutch.eu – info@ddutch.eu - +32 472 74 56 16

I have read and accept the terms and conditions as laid down by LTR/DoubleDutch.
I understand that I shall be expelled from the au pair program if any of the information proves to be false.
I agree that the personal data will be used only for the purpose as required by
the Au Pair Program

Date: Signature au pair :

Place:

____________________________________________________________________________________________________
SC Lion Trade & Brokerage SRL- DoubleDutch . Str M Eminescu 189 . Com. Vetel . Jud HD . Romania .
* IBAN: RO75 INGB 0000999907651697-EURO * * IBAN: RO28 INGB 0000999907651670-RON *
* ORC J20/259/2004 * VAT/TVA/BTW RO 16170826 *
Tel. BE +32 472745616 Tel. RO +40 737 725 228 email: info@ddutch

dd au pair agency – www.ddutch.eu – info@ddutch.eu - +32 472 74 56 16