Gen 122 Services

New Client Application Form for Family

First Name:

Surname:

Address:

Postcode:

Daytime Telephone (+code) :

Evening Telephone (+code) :

E-mail address :

About your Family

Occupation:

Nationality:

Religion:

Languages Spoken :

Marital Status :

Married Single Other

Do you have any Children :

Yes No

If yes, please specify how many :

Ages and Gender of Children :

Do the Children attend School or nursery :

Yes No

How far is the School or nursery from your home? :

Do any of the Children stay home all day? :

Yes No

Any other information regarding the children?(Special Needs,Allergies) :

Are you expecting a baby? :

Yes No

If yes please state due date :

Do you have any pets :

Yes No

If yes please state which ones? :

Does any family member have a criminal record? :

Yes No

Do you smoke:

Yes No

About Your Property

Accommodation Type:

Bungalow Flat House

If it’s a house , please specify:

Detached Terraced Semi

Number of Reception rooms :

Number of Bedrooms:

Number of Bathrooms:

Number of Floors:

Number of Toilets:

Nearest Bus/Tube Station:

Services Required

Child Care

Cleaning

Ironing

Cooking

Washing

About Your Aupair/Nanny

Length Of Service Required :

6 months 12months

Tick below duties expected of your Aupair :

Cooking Cleaning Ironing

Baby Sitting School Run Home Work

Do you have a preference for gender? :

No Preference Male Female

Age Range :

18-24 24-35 35+

Smoking Preference :

No Preference Non Smoker Smoker

Do you need an Aupair with a driving Licence?

Yes No

Will the Aupair have there own Room?

Yes No

Tick facilities available to Aupair:

Television Bathroom Radio

Use of Computer

Working hours Required?

Monday	AM	PM
Tuesday	AM	PM
Wednesday	AM	PM
Thursday	AM	PM
Friday	AM	PM
Saturday	AM	PM
Sunday	AM	PM

Your Target Weekly pay Rates?

Date you want Service to Commence

How did you locate us:

Referral Internet Adverts

Name of Person who Referred Us:

I have read the Agency's terms and condition and by submitting this form I agree to this terms.

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