Fields Marked with a * are required
Contact Name (Full Name):
Email:
Telephone (Landline):
Mobile:
*Where did you hear of us?:	Please select...Internet SearchReferred by friend/family/colleagueYellow PagesYell On LineOther
Have you had an au pair before?:	Please select...YesNo
Number of children?:	Please select...123456+0 (Housekeeping/Companion roles)
Home Location (Postcode/ name village/town/city):
Type of home location:	Select one that best describes your location..City CentreCity SuburbProvincial TownVillageFarm (working)Rural or Remote
Is Driving Required:	Please select....YesNoNo/Not important (but car available for their use)
What is your view about smoking?:	Please select...Non-Smoker onlySmoker would be OKSmoker OK but only outside the home/socially
Would you consider a male au pair?:	Please select...Female au pair onlyMale au pair onlyNot ImportantMay consider a male au pair
What age au pair would you be comfortable with??:	Please select...  Any age (not important)  17 - 18  19 - 20  21- 23  24 - 25  26 - 30  31 - 40  41 - 50  51+
Comments - Considerations - Special Requests:
Date Au Pair is required by:	None
Do you have pets?:	Please select all that apply...  Birds  Cats  Dogs  Horses  Indoor small animals (Hamsters, mice etc.)  Outdoor small animals (Rabbits, guinea pigs etc.)  Tropical fish  Other