APPLICATION FORM

Photo Please Use Black Ink When completing the following questions, please be as flexible as possible, to enable an efficient placement

PERSONAL DETAILS First name (Prenume): Address (Adresa): Surname (Nume de familie):

Landline (Telefon fix): Email (Email):

Mobile (Mobil):

Earliest start date (Data de cand puteti incepe): How long do you want to stay? (Cat timp doriti sa stati?) Minimum (Minim): Sex (Gen): Height (Inaltime): Nationality (Cetatenie): Religion (Religie): Fathers occupation (Ocupatia tatalui): Maximum (Maxim): Date of Birth (Data Nasterii): Weight (Greutate): Passport No (Numar pasaport): Practicing (Daca practicati religia): Mothers occupation (Ocupatia mamei):

No. of brothers and sisters (if you have) and ages (Frati si surori: nume si varsta):

Do you smoke? Please answer truthfully. (Fumati? Va rugam raspundeti sincer!) If so, how many per day?
(Daca Da, cate tigari pe zi?)

Would you agree to smoke only away from the home?

(Sunteti de acord sa fumati NUMAI in afara casei?)

Do you have a current driving license?

(Aveti permis de conducere valabil?)

Since when? (Data obtinerii categoriei respective)

What driving experience do you have? (Ce experienta in condus aveti?) Are you willing to drive in the UK? (Puteti si doriti sa conduceti in UK?) Do you have any allergies / disabilities / illness? If yes, please give details.
(Aveti probleme medicale? Daca da, va rugam dati detalii.)

Do you follow any special diet? If yes, please give details (e.g. vegetarian or for religious reasons).
(Urmati vreo dieta?)

What are your hobbies / interests? (Ce hobby-uri aveti?) Which sports do you regularly do? (Ce sporturi practicati?) Can you swim? (Puteti inota?) Do you like animals? (Va plac animalele?)

Can you play a musical instrument? (Puteti canta la un instrument muzical?) How well do you speak English? (Cat de bine vorbiti limba engleza?) [ ] Poor
(Slab)

[ ] Basic
(De Baza)

[ ] Average
(Mediu)

[ ] Good

[ ] Advanced
(Avansat)

Are you able to hold a conversation

(Bine) in English? (Puteti purta o conversatie in engleza?)

English years learning? (Cati ani ati invatat engleza?)

Do you read and write in English?

(Cititi si scrieti in engleza?)

Do you wish to attend English classes in UK? (Doriti sa faceti cursuri de engleza in UK?) Do you speak any other languages? (Vorbiti alte limbi straine? Daca Da, care si ce nivel?) Name, address and phone number of person(s) to contact in case of emergency:
(Datele de contact ale unui membru al familiei)

Have you lived away from home for any length of time (2 months or more)? If yes, please give details. (Ati locuit departe de casa? Daca da, va rugam dati detalii.) Have you been an Au Pair before?
(Ati mai fost prin Programul Au Pair?)

When and where? Please send reference letter from previous family, if available.
(Daca da, cand si unde? Va rugam sa atasati scrisoare de recomandare de la acea familie.)

EDUCATION / EMPLOYMENT DETAILS Last school / college / university attended (Care sunt ultimele studii?) If employed occupation (Ocupatia actuala) Previous occupations (Ocupatiile anterioare) Have you any first aid certificates? (Aveti certificat de prim ajutor?) Do you have any professional qualifications with children? Please attach copies of Diplomas.
(Aveti calificare profesionala cu copiii? Daca da, va rugam atasati copii dupa acele diplome.)

Future educational plans / future ambitions? (Planuri de viitor)

EXPERIENCE WITH CHILDREN AND HOUSEWORK What age group of children do you prefer? Please be flexible. (Ce grupe de varsta preferati?) [ ] 0 2 years
(0 2 ani)

[ ] 2 5 years
(2 5 ani)

[ ] 5 years and over

(5 ani si peste)

[ ] any age
(ORICE Varsta)

Will you accept: (Acceptati) [ ] Single mother?

(Mama Singura)

[ ] Single father?

[ ] Whole family?

(Tata Singur) (Toata Familia) Will you accept a child with mild disabilities? (Acceptati un copil cu dizabilitati usoare?)

Will you accept a family who lives in: (Acceptati o familie care locuieste in) [ ] London
(Londra)

[ ] Another city
(Alt Oras)

[ ] Countryside

[ ] Anywhere
(ORIUNDE)

Can

(Zona Rurala) you take sole charge of children? (Puteti avea grija de copii SINGUR?)

Can you take sole charge of babies? (Puteti avea grija de BEBELUSI (0 2 ani) SINGUR?) Would you accept a baby if the mother were also home?
(Acceptati un bebelus daca mama e acasa?)

What experience do you have with children? (CE experienta aveti cu copiii?)

What experience do you have with babies? (CE experienta aveti cu bebelusii: 0 2 ani?) Are you willing to live with a family with pets / animals?
(Acceptati sa locuiti cu o familie cu animale?)

Are you willing to help look after the family's pets?

(Acceptati sa aveti grija de animalele familiei?)

Can you cook basic food? (Puteti gati mancare de baza?) What experience do you have of domestic work? (CE experienta aveti cu treburile gospodaresti?) Are you prepared to help with light domestic work (e.g. washing, ironing, vacuum, dust)?
(Puteti si doriti sa ajutati la treburile gospodaresti?)

Do you plan to return to your home country during your stay in the UK? If so, when? (Doriti sa va intoarceti in tara pe perioada contractului? Daca da, va rugam precizati perioada.) How would you best describe your personality? (Cum va descrieti personalitatea?)

I certify that all the above information is correct. I understand and I am in full agreement with the Terms and Conditions of Business of the Agency. (Confirm faptul ca toate informatiile mentionate sunt corecte. Am luat la cunostinta despre termenii si conditiile agentiei si sunt de acord sa le respect.)

SIGNATURE*

DATE

* I agree my digital signature is equal to a handwritten signature