Full Name*

Address*

Age*

Languages spoken*

Contact Details

Phone*

Mobile

E-Mail Address

Nationality*

NIE number/Passport*

Days and times available

Date you are available to start work*

January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007

Education history, including any childcare qualifications*

Relevant experience*

Do you drive? If so, do you have any convictions or have you ever had an accident?

Do you own a car?

Yes

No

Do you smoke?

Yes

No

Do you have any recurring medical problems? Including asthma or allergies?

Please give the names, addresses and phone contact of two people who would be prepared to give you a reference regarding childcare (not including family members)

DECLARATION FOR ALL APLICATIONS

Have you ever had an accident while caring for a child? If so please give details

Has a child ever had an accident whilst in your care? If so please give details

Do you have a police record? If so please give details

Have you had or are you prepared to have a police check?

Yes

No

FINAL DECLARATION*

I certify that the information set out above is true and correct. I authorise TLC to use this information, without prejudice, at its sole discretion, I further authorise TLC to verify any references which I have supplied. I will treat all information given to me regarding vacant positions as confidential and will not pass on any names and addresses of potential employers to any person or give any personal information or contact details to any client or potential client of Tender Loving Canguros SL. If I obtain a position through TLC, I will notify them at once and will notify the employer concerned that the agency fee will apply.

I Agree I Disagree.