Application Form For Au Pair

I would like to work as Au Pair in
Name
Address ( country, city, zip code, street, ect. )
Phone / Fax
E-mail (double check!)
Citizenship
Civil life
Do you have brothers / sisters, if yes what age
Do you have any experience with children, if yes what age were they at that time
Do you have a driving licence, if yes from what time
Do you have criminal record
Do you smoke
When you can start your work
Education
Basic school (1-9)	what year
Basic school (1-3)	what year
College	what year
Other education	what year
Profession (have you worked before)	if yes, where
Have you worked as Au Pair before, if yes where and how long time	in
Do you have any references from those families or others which know you well	from :
Are you allergic against something	if yes what :
What child diseases have you had	specify which
Have you any serious sickness lately	if yes what :
Which languages do you speak
I would be interested in language course to better my :
Tell us about your hobbies
How many children are you able to take care off in you hostfamily	number of children what ages
Are you able to send us your medical sertificate if family require that
Can you swim
Are you vegetarian
Do you like pets
have you worked with handicap children
Dou you accept a single parent
Are you registered in some other agency now
Additional comments ( if any )