Agent AuPair - Au Pair Form

Yes, I would like to learn more about being an Au Pair in the USA!
Your Name:*

First NameLast Name
Your E-mail Address*
Your Phone Number:*

Country or Area CodePhone Number
Your Country of Residence:*
Your Passport is Issued by: Select Country:*
Your Current Age:*
I am ready to commit to a 1 Year Program in the USA:*

YesNoNot Sure
I am willing to be placed anywhere in the USA:*

YesNo
Your English Language level is:*

ExcellentGoodFairBeginner
Your Child Care Experience:*

More than 6 Months of ExperienceLess than 6 Months of ExperienceNo Experience
Your Driving Experience:*

Have a Drivers LicenseDo Not Have a Drivers LicenseI am working towards a Drivers License
Your Preferred Timeline for Placement:*

ImmediatelyIn the next 3 monthsAt some point in 2016Not Sure
Comments or Questions:
*Yes. Please contact me at the number I have provided regarding additional information about AuPair.com and Agent AuPair. We respect your privacy and will not sell your contact or personal information.

Agent AuPair is a trusted partner of AuPair.com and provides au pair and international education opportunities of the highest quality.
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Yes, I would like to learn more about being an Au Pair in the USA!