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Au Pair International

Host Family Confidential Reference from Employer or Business Partner To: Au Pair International

From: _________________________________

Fax to: 720-221-0724

Phone: ________________________________ Fax: ___________________________________

This form is to be completed by a current employer or business partner of Applicant and sent directly to: Au Pair International, 4450 Arapahoe Ave, Suite 100, Boulder, CO 80303 or fax it to 720-221-0724. Any reference which poses a concern will be discussed tactfully with the applicant(s) to (if possible) resolve issues before the decision of placing an au pair in their home is made). Please feel free to contact us if you have any questions at: 888-649-2876 or email: hostfamily@aupairint.com. If self employed: please provide second personal reference in lieu of reference from employer or business partner. Name of Applicant:________________________________ _____________________________ Home address: __________________________________________________________________ City: ____________________________________________ State:__________ Zip: __________

Name of individual providing reference: _____________________________________________ Company name: __________________________________________ Title: _________________ Address:_______________________________________________________________________ City:__________________________________ ________ State:___________ Zip: ___________ Work telephone: _________________________________________ Ext:___________________ How long has the Applicant been employed by the company?____________________________ Or If business partner; how long have you been a business partner of the Applicant?__________ Applicant’s current title/position ___________________________________________________ Would the Applicant in your opinion be suitable to include an international exchange participant as a member of his/her family for a year? Yes No If no, please explain: ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ Signature of reference Date Office use only: Au Pair International, Host Family Personal Reference Form. Phone: 888-649-2876 Fax: 720-221-0724 hfer-0108


Au Pair International

Second Host Family Personal Reference In lieu of Employer or Business Partner Reference To: Au Pair International

From: _________________________________

Fax to: 720-221-0724

Phone: ________________________________ Fax: ___________________________________

The applicant is applying to host an Au Pair International au pair from a foreign country in their home for a year. This form is to be completed by someone other than a family member who has known the applicant(s) for at least two years, who can accurately attest to the family life and commitment the host family would have to the au pair program. Please send completed form to: Au Pair International, 4450 Arapahoe Ave, Suite 100, Boulder, CO 80303 or fax it to 720-221-0724. Any reference which poses a concern will be discussed tactfully with the applicant(s) to (if possible) resolve issues before the decision of placing an au pair in their home is made. Please feel free to contact us if you have any questions at: 888-6492876 or email: hostfamily@aupairint.com Name(s) of Applicant(s):_______________________ __________________________________ Applicant(s) home address: _______________________________________________________ City: ___________________________________________ State:___________ Zip: __________

Name of individual providing reference:______________________________________________ Occupation:____________________________________________________________________ City: ________________________________________ State:__________ Zip: _____________ Home phone: _________________________

Work phone number: ____________________

How long have you known the Applicant(s)? _________________________________________ Please describe your relationship to the Applicant(s): ___________________________________ _____________________________________________________________________________________

Have you visited the Applicant family in their home?

Yes

No

If yes, how frequently?

______________________________________________________________________________ ______________________________________________________________________________ Please describe your view of the family, including your observations of the parents’ relationship with each other and the parents’ relationship with the children: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Au Pair International, Host Family Personal Reference Form. Phone: 888-649-2876 Fax: 720-221-0724 hfer-0108


Name(s) of Applicant(s): ________________________________________________________ Are you aware of any unusual conditions, including physical, emotional or health that the children or parents may have: Yes No If yes, please explain: ______________________________________________________________________________ ______________________________________________________________________________ Are you aware of any drug or alcohol abuse, domestic violence, sexual abuse, verbal abuse or any criminal behavior involving any family members or other dysfunction in the family: Yes No If yes, please explain: ______________________________________________________________________________ ______________________________________________________________________________ Please give your impression of the Host Family Applicant(s) in regards to (please circle): Physical Health: Mental Health: Moral Standards: Personality: Values: Cleanliness/Neatness: Job Security: Cultural Tolerance: Financial Stability:

Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent

Very Good Very Good Very Good Very Good Very Good Very Good Very Good Very Good Very Good

Good Good Good Good Good Good Good Good Good

Fair Fair Fair Fair Fair Fair Fair Fair Fair

Poor Poor Poor Poor Poor Poor Poor Poor Poor

If rated “fair” or “poor”, please explain why you feel so and to whom you are referring: ______________________________________________________________________________ ______________________________________________________________________________ In your opinion, is the family suitable to include an international exchange participant as a member of their family for a year? Yes No If no, please explain: ______________________________________________________________________________ ______________________________________________________________________________ Are you aware of any other problems, conditions or issues that you think the au pair should know about before moving in with the family: Yes No If yes, please explain: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Signature of Reference Date Office use only:

Au Pair International, Host Family Personal Reference Form. Phone: 888-649-2876 Fax: 720-221-0724 hfer-0108


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