Housekeeper Form

Please complete this online form with as many details as possible to enable us to find a suitable placement for you.
Boxes with an asterisk * must be filled in.

Personal Details

    Surname (family name): *

    First Names: *

    Address (house name/number and street):


    Postal Code:


    Phone Number (please include the country and area code): *

    Mobile Number (please include the country and area code):


    Email Address: *





    Date of Birth:

    Place of Birth:

    Passport or Identity Card Number:

    Recent photographs of yourself and/or with children and babies

    Do you wish to be a housekeeper, or would you consider being an au pair, mother's help, or nanny?

    housekeeperau pairmother's helpnanny

    Would you prefer a live-in or live-out position?


    When do you wish to commence employment?

    Length of Employment:

    Salary/Pocket Money Required:


    Father's Profession:

    Mother's Profession:

    Parent's Address: (if you are not living at home)

    Parent's Phone Number: (if different from above)

    Do you have any brothers or sisters?



    Last School/College/University Attended:

    Examinations/Qualifications Obtained:

    How long have you studied English? (not applicable to British Nationals)

    Is your English: Basic, fair, good or excellent?


    Other languages spoken:

    Please state whether your knowledge of any other spoken languages is: basic, fair, good, or excellent:

    Current Occupation:

    Length of notice to be given:

    Previous Occupation:

    Do you have any First Aid or CPR Certification?


    Do you have any other certificates? (certificates of merit, swimming, music, sports, etc.):

    Do you have any formal childcare qualifications?


    If yes, which qualifications do you have?


    Please state if you are experienced or comfortable with childcare:

    Please state if you are experienced or comfortable with housework:

    Please state if you are willing to work with the following:

    Infants (0-6 Months Old)Infants (6-12 Months Old)Children (1-2 Years Old)Children (2-5 Years Old)Children (5-10 Years Old)Families of a different raceFamilies with a single motherFamilies with a single father

    If you have experience with children can you supply childcare references?

    What type of housework have you done in the past?

    Can you cook?


    If yes, please describe your level of expertise, and describe some dishes, etc., you can cook:

    Are you in good health?


    If not, from what do you suffer?

    Do you have any allergies?


    If yes, what allergies do you have?

    Do you have a criminal record?


    If yes, what were you convicted of?

    Do you eat everything?


    If no, what do you not eat, or what are your dietary restraints (such as religious restraints)?

    Do you smoke?


    If yes, then how many per day?

    Would you agree not to smoke in the family's home?


    Which sports do you play?

    Do you play a musical instrument? And if so, which instrument?

    Do you like animals?


    If yes, which animals do you like?

    Do you have a driving licence?


    If yes, please state the date you passed your test:

    Would you drive abroad?


    Please give details of hobbies or interests, and/or any further information that you feel might help us find the right position for you:


    I fully understand the Agency's conditions, and agree to abide by these conditions. Furthermore, all the details given by me on this application form are correct.

    I agree to the above declaration (please state that you agree): *

    Electronic Signature: (please state your name): *

    Additional items that you will be asked to send by post or e-mail when this form is positively processed:

    1. One pleasant passport photograph with your name on reverse.
    2. At least two large photographs showing you with children/babies (if not previously sent).
    3. A medical certificate stating you are fit to work with children.
    4. Two references will be required from previous employers with a phone number and e-mail address for each.
    5. If you have requested a nanny placement, copy of NNEB or similar certificates, should accompany your application form.
    6. A police record check.
    7. A “Dear Family” letter telling us about you, and any childcare and cleaning experience.

    If you have any further pictures or scanned images or documents ready, as needed above, you may also e-mail these at the time you send the photographs to
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