ÿþ<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> <html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en"> <head> <title>1st Choice Au Pairs - UK Au Pair Agency - On-Line Registration</title> <LINK REV="made" href="mailto:webmaster@1stchoiceaupairs.eu"> <META NAME="keywords" CONTENT="Au Pair, England, Great Britain, London, Au Pair Agency"> <META NAME="description" CONTENT="We are one agency who deals directly with both our families and au pairs. Our agency will support you before and during your stay in the UK. Our team is both British and Slovak"> <META NAME="author" CONTENT="Jay Poole"> <META NAME="ROBOTS" CONTENT="ALL"> <style type="text/css"> /* **** NOTES **** */ /* I have tried to comment this style sheet as much as possible to show you where things take place. 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#dda; padding: 6px} </style> </head> <body> <div id="container"> <div id="header"><h1><a href="#">1st Choice Au Pairs</a></h1> <p id="skip"><a href="#content">Skip To Content</a></p></div> <div id="wrapper"> <!-- Main content section --> <div id="content"> <h2 id="topper">Au Pair Registration Form</h2> <!-- #public_form# start --><!-- do not change this line --> <form action="http://www.trackvia.com/app/publicticket" method="post" enctype="multipart/form-data"> <input type="hidden" name="datasetid" value="24624"> <input type="hidden" name="securitycode" value="m801duClP0czP8Cd2CPT"> <p>* = required field</p> <table class='publicform'> <tr> <td>Full Name (Firstname Surname) *</td> <td> <input type="text" name="varchar000" id="varchar000" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>First Name *</td> <td> <input type="text" name="varchar001" id="varchar001" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Surname</td> <td> <input type="text" name="varchar002" id="varchar002" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Sex *</td> <td> <select name="text000"> <option value="">&nbsp; <option value="Female" >Female <option value="Male" >Male </select> </td> </tr> <tr> <td>Height (cm)</td> <td> <select name="text002"> <option value="">&nbsp; <option value="&lt;140" >&lt;140 <option value="141" >141 <option value="142" >142 <option value="143" >143 <option value="144" >144 <option value="145" >145 <option value="146" >146 <option value="147" >147 <option value="148" >148 <option value="149" >149 <option value="150" >150 <option value="151" >151 <option value="152" >152 <option value="153" >153 <option value="154" >154 <option value="155" >155 <option value="156" >156 <option value="157" >157 <option value="158" >158 <option value="159" >159 <option value="160" >160 <option value="161" >161 <option value="162" >162 <option value="163" >163 <option value="164" >164 <option value="165" >165 <option value="166" >166 <option value="167" >167 <option value="168" >168 <option value="169" >169 <option value="170" >170 <option value="171" >171 <option value="172" >172 <option value="173" >173 <option value="174" >174 <option value="175" >175 <option value="176" >176 <option value="177" >177 <option value="178" >178 <option value="179" >179 <option value="180" >180 <option value="181" >181 <option value="182" >182 <option value="183" >183 <option value="184" >184 <option value="185" >185 <option value="186" >186 <option value="187" >187 <option value="188" >188 <option value="189" >189 <option value="190" >190 <option value="191" >191 <option value="192" >192 <option value="193" >193 <option value="194" >194 <option value="195" >195 <option value="196" >196 <option value="197" >197 <option value="198" >198 <option value="199" >199 <option value="200" >200 <option value="&gt;200" >&gt;200 </select> </td> </tr> <tr> <td>Weight (kg)</td> <td> <select name="text003"> <option value="">&nbsp; <option value="&lt;40" >&lt;40 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="51" >51 <option value="52" >52 <option value="53" >53 <option value="54" >54 <option value="55" >55 <option value="56" >56 <option value="57" >57 <option value="58" >58 <option value="59" >59 <option value="60" >60 <option value="61" >61 <option value="62" >62 <option value="63" >63 <option value="64" >64 <option value="65" >65 <option value="66" >66 <option value="67" >67 <option value="68" >68 <option value="69" >69 <option value="70" >70 <option value="71" >71 <option value="72" >72 <option value="73" >73 <option value="74" >74 <option value="75" >75 <option value="76" >76 <option value="77" >77 <option value="78" >78 <option value="79" >79 <option value="80" >80 <option value="81" >81 <option value="82" >82 <option value="83" >83 <option value="84" >84 <option value="85" >85 <option value="86" >86 <option value="87" >87 <option value="88" >88 <option value="89" >89 <option value="90" >90 <option value="91" >91 <option value="92" >92 <option value="93" >93 <option value="94" >94 <option value="95" >95 <option value="96" >96 <option value="97" >97 <option value="98" >98 <option value="99" >99 <option value="100" >100 <option value="&gt;100" >&gt;100 </select> </td> </tr> <tr> <td>Date of Birth *</td> <td> <select name="datetime000-d" id="datetime000-d"> <option value="--" selected> <option value="01" >1 <option value="02" >2 <option value="03" >3 <option value="04" >4 <option value="05" >5 <option value="06" >6 <option value="07" >7 <option value="08" >8 <option value="09" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 </select> <nobr><select name="datetime000-mon" id="datetime000-mon"> <option value="--" selected> <option value="01" >Jan <option value="02" >Feb <option value="03" >Mar <option value="04" >Apr <option value="05" >May <option value="06" >Jun <option value="07" >Jul <option value="08" >Aug <option value="09" >Sep <option value="10" >Oct <option value="11" >Nov <option value="12" >Dec </select> <select name="datetime000-y" id="datetime000-y"> <option value="----" selected></option><option value="1948">1948</option><option value="1949">1949</option><option value="1950">1950</option><option value="1951">1951</option><option value="1952">1952</option><option value="1953">1953</option><option value="1954">1954</option><option value="1955">1955</option><option value="1956">1956</option><option value="1957">1957</option><option value="1958">1958</option><option value="1959">1959</option><option value="1960">1960</option><option value="1961">1961</option><option value="1962">1962</option><option value="1963">1963</option><option value="1964">1964</option><option value="1965">1965</option><option value="1966">1966</option><option value="1967">1967</option><option value="1968">1968</option><option value="1969">1969</option><option value="1970">1970</option><option value="1971">1971</option><option value="1972">1972</option><option value="1973">1973</option><option value="1974">1974</option><option value="1975">1975</option><option value="1976">1976</option><option value="1977">1977</option><option value="1978">1978</option><option value="1979">1979</option><option value="1980">1980</option><option value="1981">1981</option><option value="1982">1982</option><option value="1983">1983</option><option value="1984">1984</option><option value="1985">1985</option><option value="1986">1986</option><option value="1987">1987</option><option value="1988">1988</option><option value="1989">1989</option><option value="1990">1990</option><option value="1991">1991</option><option value="1992">1992</option><option value="1993">1993</option><option value="1994">1994</option><option value="1995">1995</option><option value="1996">1996</option><option value="1997">1997</option><option value="1998">1998</option><option value="1999">1999</option><option value="2000">2000</option><option value="2001">2001</option><option value="2002">2002</option><option value="2003">2003</option><option value="2004">2004</option><option value="2005">2005</option><option value="2006">2006</option><option value="2007">2007</option><option value="2008">2008</option><option value="2009">2009</option><option value="2010">2010</option></select> <input type="hidden" id="datetime000-h" name="datetime000-h" value="12"><input type="hidden" id="datetime000-min" name="datetime000-min" value="00"><input type="hidden" id="datetime000-am_pm" name="datetime000-am_pm" value="PM"><input type="hidden" id="datetime000-tz" name="datetime000-tz" value="America/Denver">&nbsp;</nobr> </td> </tr> <tr> <td>Nationality (country) *</td> <td> <select name="text001"> <option value="">&nbsp; <option value="Croatia" >Croatia <option value="Czech Republic" >Czech Republic <option value="France" >France <option value="Germany" >Germany <option value="Hungary" >Hungary <option value="Italy" >Italy <option value="Moldavia" >Moldavia <option value="Poland" >Poland <option value="Romania" >Romania <option value="Russia" >Russia <option value="Slovakia" >Slovakia <option value="Slovenia" >Slovenia <option value="Spain" >Spain <option value="Sweden" >Sweden <option value="Turkey" >Turkey <option value="United Kingdom" >United Kingdom <option value="other" >other </select> </td> </tr> <tr> <td>Religion</td> <td> <input type="text" name="varchar004" id="varchar004" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Practising</td> <td> <select name="text004"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No <option value="Occasionally" >Occasionally </select> </td> </tr> <tr> <td>I live in (home location)</td> <td> <input type="text" name="varchar005" id="varchar005" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Type of Location</td> <td> <select name="text005"> <option value="">&nbsp; <option value="City" >City <option value="Town" >Town <option value="Village" >Village <option value="Rural/Farm" >Rural/Farm </select> </td> </tr> <tr> <td>Telephone No.</td> <td> <input type="text" name="double001" id="double001" size="8" value=""> </td> </tr> <tr> <td>Mobile No.</td> <td> <input type="text" name="double002" id="double002" size="8" value=""> </td> </tr> <tr> <td>Fax No.</td> <td> <input type="text" name="double003" id="double003" size="8" value=""> </td> </tr> <tr> <td>Email</td> <td> <input type="text" name="varchar006" id="varchar006" size="40" maxlength="120" value=""> </td> </tr> <tr> <td>Address</td> <td> <input type="text" name="varchar007" id="varchar007" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Address (during College)</td> <td> <input type="text" name="varchar008" id="varchar008" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Contact Preference</td> <td> <select name="text006"> <option value="">&nbsp; <option value="Email" >Email <option value="SMS" >SMS <option value="Landline" >Landline <option value="Post" >Post <option value="None" >None </select> </td> </tr> <tr> <td>Contact (2nd Choice)</td> <td> <select name="text007"> <option value="">&nbsp; <option value="Email" >Email <option value="SMS" >SMS <option value="Landline" >Landline <option value="Post" >Post <option value="None" >None </select> </td> </tr> <tr> <td>Photograph 1</td> <td> <input type="hidden" id="docstatus010" name="docstatus010" value="normal"><input type="file" name="varchar010" size="30"> </td> </tr> <tr> <td>Photograph 2</td> <td> <input type="hidden" id="docstatus012" name="docstatus012" value="normal"><input type="file" name="varchar012" size="30"> </td> </tr> <tr> <td>Photograph 3</td> <td> <input type="hidden" id="docstatus014" name="docstatus014" value="normal"><input type="file" name="varchar014" size="30"> </td> </tr> <tr> <td>Photograph 4</td> <td> <input type="hidden" id="docstatus016" name="docstatus016" value="normal"><input type="file" name="varchar016" size="30"> </td> </tr> <tr> <td>Photograph 5</td> <td> <input type="hidden" id="docstatus017" name="docstatus017" value="normal"><input type="file" name="varchar017" size="30"> </td> </tr> <tr> <td>You Are... *</td> <td> <select name="text008"> <option value="">&nbsp; <option value="Attending School/College" >Attending School/College <option value="Unemployed" >Unemployed <option value="Working(complete section below)" >Working(complete section below) </select> </td> </tr> <tr> <td>Highest Qualification</td> <td> <select name="text009"> <option value="">&nbsp; <option value="Bcc degree" >Bcc degree <option value="Doctorate" >Doctorate <option value="High school diploma" >High school diploma <option value="Masters degree" >Masters degree <option value="Primary school" >Primary school <option value="Secondary Grammar school" >Secondary Grammar school <option value="Secondary school" >Secondary school <option value="University degree" >University degree </select> </td> </tr> <tr> <td>If Working Give Details Below</td> <td> <textarea rows="5" cols="50" name="text051" id="text051"></textarea> </td> </tr> <tr> <td>If Studying Give Details Below</td> <td> <textarea rows="5" cols="50" name="text050" id="text050"></textarea> </td> </tr> <tr> <td>Fathers Job</td> <td> <input type="text" name="varchar020" id="varchar020" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Fathers Age</td> <td> <select name="text010"> <option value="">&nbsp; <option value="&lt;34" >&lt;34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="51" >51 <option value="52" >52 <option value="53" >53 <option value="54" >54 <option value="55" >55 <option value="56" >56 <option value="57" >57 <option value="58" >58 <option value="59" >59 <option value="60" >60 <option value="61" >61 <option value="62" >62 <option value="63" >63 <option value="64" >64 <option value="65" >65 <option value="66" >66 <option value="67" >67 <option value="68" >68 <option value="69" >69 <option value="70" >70 <option value="&gt;70" >&gt;70 </select> </td> </tr> <tr> <td>Mothers Job</td> <td> <input type="text" name="varchar021" id="varchar021" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Mothers Age</td> <td> <select name="text011"> <option value="">&nbsp; <option value="&lt;34" >&lt;34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="51" >51 <option value="52" >52 <option value="53" >53 <option value="54" >54 <option value="55" >55 <option value="56" >56 <option value="57" >57 <option value="58" >58 <option value="59" >59 <option value="60" >60 <option value="61" >61 <option value="62" >62 <option value="63" >63 <option value="64" >64 <option value="65" >65 <option value="66" >66 <option value="67" >67 <option value="68" >68 <option value="69" >69 <option value="70" >70 <option value="&gt;70" >&gt;70 </select> </td> </tr> <tr> <td>Age Of Brother 1</td> <td> <select name="text012"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 <option value="32" >32 <option value="33" >33 <option value="34" >34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="&gt;50" >&gt;50 </select> </td> </tr> <tr> <td>Age Of Brother 2</td> <td> <select name="text013"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 <option value="32" >32 <option value="33" >33 <option value="34" >34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="&gt;50" >&gt;50 </select> </td> </tr> <tr> <td>Age Of Brother 3</td> <td> <select name="text014"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 <option value="32" >32 <option value="33" >33 <option value="34" >34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="&gt;50" >&gt;50 </select> </td> </tr> <tr> <td>Age Of Brother 4</td> <td> <select name="text015"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 <option value="32" >32 <option value="33" >33 <option value="34" >34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="&gt;50" >&gt;50 </select> </td> </tr> <tr> <td>Age Of Sister 1</td> <td> <select name="text016"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 <option value="32" >32 <option value="33" >33 <option value="34" >34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="&gt;50" >&gt;50 </select> </td> </tr> <tr> <td>Age Of Sister 2</td> <td> <select name="text017"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 <option value="32" >32 <option value="33" >33 <option value="34" >34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="&gt;50" >&gt;50 </select> </td> </tr> <tr> <td>Age Of Sister 3</td> <td> <select name="text018"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 <option value="32" >32 <option value="33" >33 <option value="34" >34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="&gt;50" >&gt;50 </select> </td> </tr> <tr> <td>Age Of Sister 4</td> <td> <select name="text019"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 <option value="32" >32 <option value="33" >33 <option value="34" >34 <option value="35" >35 <option value="36" >36 <option value="37" >37 <option value="38" >38 <option value="39" >39 <option value="40" >40 <option value="41" >41 <option value="42" >42 <option value="43" >43 <option value="44" >44 <option value="45" >45 <option value="46" >46 <option value="47" >47 <option value="48" >48 <option value="49" >49 <option value="50" >50 <option value="&gt;50" >&gt;50 </select> </td> </tr> <tr> <td>Number Of Years Of English Study</td> <td> <select name="text020"> <option value="">&nbsp; <option value="&lt;1" >&lt;1 <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="&gt;10" >&gt;10 </select> </td> </tr> <tr> <td>How Would You Rate Your English Skills *</td> <td> <select name="text021"> <option value="">&nbsp; <option value="Basic" >Basic <option value="Fair" >Fair <option value="Fluent" >Fluent <option value="Good" >Good </select> </td> </tr> <tr> <td>I Plan To Attend Language Classes In The UK (study)</td> <td> <select name="text022"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No <option value="Not sure" >Not sure <option value="Possibly" >Possibly </select> </td> </tr> <tr> <td>I Wish To Take Qualifications In English In The UK</td> <td> <select name="text023"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No <option value="Not sure" >Not sure <option value="Possibly" >Possibly </select> </td> </tr> <tr> <td>Languages</td> <td> <fieldset> <table border="0" id="checkbox_table_text035-"> <tr> <td valign="top"><input type="checkbox" name="text035-Hungarian" id="text035-Hungarian"><label for="text035-Hungarian">&nbsp;Hungarian</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text035-Polish" id="text035-Polish"><label for="text035-Polish">&nbsp;Polish</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text035-Czech" id="text035-Czech"><label for="text035-Czech">&nbsp;Czech</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text035-French" id="text035-French"><label for="text035-French">&nbsp;French</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text035-Russian" id="text035-Russian"><label for="text035-Russian">&nbsp;Russian</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text035-Slovak" id="text035-Slovak"><label for="text035-Slovak">&nbsp;Slovak</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text035-German" id="text035-German"><label for="text035-German">&nbsp;German</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text035-Spanish" id="text035-Spanish"><label for="text035-Spanish">&nbsp;Spanish</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text035-Romanian" id="text035-Romanian"><label for="text035-Romanian">&nbsp;Romanian</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text035-Italian" id="text035-Italian"><label for="text035-Italian">&nbsp;Italian</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>Have You Passed A Driving Test? *</td> <td> <select name="text034"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>Date Of Issue</td> <td> <select name="datetime001-d" id="datetime001-d"> <option value="--" selected> <option value="01" >1 <option value="02" >2 <option value="03" >3 <option value="04" >4 <option value="05" >5 <option value="06" >6 <option value="07" >7 <option value="08" >8 <option value="09" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 </select> <nobr><select name="datetime001-mon" id="datetime001-mon"> <option value="--" selected> <option value="01" >Jan <option value="02" >Feb <option value="03" >Mar <option value="04" >Apr <option value="05" >May <option value="06" >Jun <option value="07" >Jul <option value="08" >Aug <option value="09" >Sep <option value="10" >Oct <option value="11" >Nov <option value="12" >Dec </select> <select name="datetime001-y" id="datetime001-y"> <option value="----" selected></option><option value="1960">1960</option><option value="1961">1961</option><option value="1962">1962</option><option value="1963">1963</option><option value="1964">1964</option><option value="1965">1965</option><option value="1966">1966</option><option value="1967">1967</option><option value="1968">1968</option><option value="1969">1969</option><option value="1970">1970</option><option value="1971">1971</option><option value="1972">1972</option><option value="1973">1973</option><option value="1974">1974</option><option value="1975">1975</option><option value="1976">1976</option><option value="1977">1977</option><option value="1978">1978</option><option value="1979">1979</option><option value="1980">1980</option><option value="1981">1981</option><option value="1982">1982</option><option value="1983">1983</option><option value="1984">1984</option><option value="1985">1985</option><option value="1986">1986</option><option value="1987">1987</option><option value="1988">1988</option><option value="1989">1989</option><option value="1990">1990</option><option value="1991">1991</option><option value="1992">1992</option><option value="1993">1993</option><option value="1994">1994</option><option value="1995">1995</option><option value="1996">1996</option><option value="1997">1997</option><option value="1998">1998</option><option value="1999">1999</option><option value="2000">2000</option><option value="2001">2001</option><option value="2002">2002</option><option value="2003">2003</option><option value="2004">2004</option><option value="2005">2005</option><option value="2006">2006</option><option value="2007">2007</option><option value="2008">2008</option><option value="2009">2009</option><option value="2010">2010</option></select> <input type="hidden" id="datetime001-h" name="datetime001-h" value="12"><input type="hidden" id="datetime001-min" name="datetime001-min" value="00"><input type="hidden" id="datetime001-am_pm" name="datetime001-am_pm" value="PM"><input type="hidden" id="datetime001-tz" name="datetime001-tz" value="America/Denver">&nbsp;</nobr> </td> </tr> <tr> <td>International Driving Licence?</td> <td> <select name="text036"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>Licence Of European Union?</td> <td> <select name="text037"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>How Often Do You Drive? *</td> <td> <select name="text038"> <option value="">&nbsp; <option value="Every day" >Every day <option value="3-4 times a week" >3-4 times a week <option value="1-2 times a week" >1-2 times a week <option value="1-2 times a month" >1-2 times a month <option value="Few times a year" >Few times a year <option value="I can&rsquo;t drive" >I can&rsquo;t drive </select> </td> </tr> <tr> <td>Earliest Start Date *</td> <td> <select name="datetime002-d" id="datetime002-d"> <option value="--" selected> <option value="01" >1 <option value="02" >2 <option value="03" >3 <option value="04" >4 <option value="05" >5 <option value="06" >6 <option value="07" >7 <option value="08" >8 <option value="09" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 </select> <nobr><select name="datetime002-mon" id="datetime002-mon"> <option value="--" selected> <option value="01" >Jan <option value="02" >Feb <option value="03" >Mar <option value="04" >Apr <option value="05" >May <option value="06" >Jun <option value="07" >Jul <option value="08" >Aug <option value="09" >Sep <option value="10" >Oct <option value="11" >Nov <option value="12" >Dec </select> <select name="datetime002-y" id="datetime002-y"> <option value="----" selected></option><option value="2004">2004</option><option value="2005">2005</option><option value="2006">2006</option><option value="2007">2007</option><option value="2008">2008</option><option value="2009">2009</option><option value="2010">2010</option><option value="2011">2011</option><option value="2012">2012</option> <input type="hidden" id="datetime002-h" name="datetime002-h" value="12"><input type="hidden" id="datetime002-min" name="datetime002-min" value="00"><input type="hidden" id="datetime002-am_pm" name="datetime002-am_pm" value="PM"><input type="hidden" id="datetime002-tz" name="datetime002-tz" value="America/Denver">&nbsp;</nobr> </td> </tr> <tr> <td>Latest Start Date</td> <td> <select name="datetime003-d" id="datetime003-d"> <option value="--" selected> <option value="01" >1 <option value="02" >2 <option value="03" >3 <option value="04" >4 <option value="05" >5 <option value="06" >6 <option value="07" >7 <option value="08" >8 <option value="09" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="25" >25 <option value="26" >26 <option value="27" >27 <option value="28" >28 <option value="29" >29 <option value="30" >30 <option value="31" >31 </select> <nobr><select name="datetime003-mon" id="datetime003-mon"> <option value="--" selected> <option value="01" >Jan <option value="02" >Feb <option value="03" >Mar <option value="04" >Apr <option value="05" >May <option value="06" >Jun <option value="07" >Jul <option value="08" >Aug <option value="09" >Sep <option value="10" >Oct <option value="11" >Nov <option value="12" >Dec </select> <select name="datetime003-y" id="datetime003-y"> <option value="----" selected></option><option value="2004">2004</option><option value="2005">2005</option><option value="2006">2006</option><option value="2007">2007</option><option value="2008">2008</option><option value="2009">2009</option><option value="2010">2010</option><option value="2011">2011</option><option value="2012">2012</option> <input type="hidden" id="datetime003-h" name="datetime003-h" value="12"><input type="hidden" id="datetime003-min" name="datetime003-min" value="00"><input type="hidden" id="datetime003-am_pm" name="datetime003-am_pm" value="PM"><input type="hidden" id="datetime003-tz" name="datetime003-tz" value="America/Denver">&nbsp;</nobr> </td> </tr> <tr> <td>Preferred Period Of Stay - In Months *</td> <td> <select name="text039"> <option value="">&nbsp; <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="&gt;24" >&gt;24 </select> </td> </tr> <tr> <td>Can This Be Extended?</td> <td> <select name="text040"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>By How Many Months?</td> <td> <select name="text041"> <option value="">&nbsp; <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="&gt;12" >&gt;12 </select> </td> </tr> <tr> <td>Are You Able To Stay In UK Over?</td> <td> <fieldset> <table border="0" id="checkbox_table_text042-"> <tr> <td valign="top"><input type="checkbox" name="text042-Christmas" id="text042-Christmas"><label for="text042-Christmas">&nbsp;Christmas</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text042-Easter" id="text042-Easter"><label for="text042-Easter">&nbsp;Easter</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text042-Summer Holiday" id="text042-Summer Holiday"><label for="text042-Summer Holiday">&nbsp;Summer Holiday</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>Preferred Locations</td> <td> <fieldset> <table border="0" id="checkbox_table_text047-"> <tr> <td valign="top"><input type="checkbox" name="text047-Town" id="text047-Town"><label for="text047-Town">&nbsp;Town</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text047-Village" id="text047-Village"><label for="text047-Village">&nbsp;Village</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text047-City" id="text047-City"><label for="text047-City">&nbsp;City</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text047-Rural/Farm" id="text047-Rural/Farm"><label for="text047-Rural/Farm">&nbsp;Rural/Farm</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>FamilyType Preferred</td> <td> <fieldset> <table border="0" id="checkbox_table_text119-"> <tr> <td valign="top"><input type="checkbox" name="text119-Mother/father+children" id="text119-Mother/father+children"><label for="text119-Mother/father+children">&nbsp;Mother/father+children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text119-Mother/father Only" id="text119-Mother/father Only"><label for="text119-Mother/father Only">&nbsp;Mother/father Only</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text119-Mother+children" id="text119-Mother+children"><label for="text119-Mother+children">&nbsp;Mother+children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text119-With Live-in Elderly Relative" id="text119-With Live-in Elderly Relative"><label for="text119-With Live-in Elderly Relative">&nbsp;With Live-in Elderly Relative</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text119-Father+children" id="text119-Father+children"><label for="text119-Father+children">&nbsp;Father+children</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>Ages Of Children Preferred</td> <td> <fieldset> <table border="0" id="checkbox_table_text060-"> <tr> <td valign="top"><input type="checkbox" name="text060-Donrsquot mind" id="text060-Donrsquot mind"><label for="text060-Donrsquot mind">&nbsp;Don&rsquo;t mind</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text060-6-10" id="text060-6-10"><label for="text060-6-10">&nbsp;6-10</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text060-0-2" id="text060-0-2"><label for="text060-0-2">&nbsp;0-2</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text060-10+" id="text060-10+"><label for="text060-10+">&nbsp;10+</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text060-2-5" id="text060-2-5"><label for="text060-2-5">&nbsp;2-5</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>What Work Are You Prepared To Do In A Family</td> <td> <fieldset> <table border="0" id="checkbox_table_text066-"> <tr> <td valign="top"><input type="checkbox" name="text066-Care for Babies" id="text066-Care for Babies"><label for="text066-Care for Babies">&nbsp;Care for Babies</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Light Housework" id="text066-Light Housework"><label for="text066-Light Housework">&nbsp;Light Housework</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Gardening" id="text066-Gardening"><label for="text066-Gardening">&nbsp;Gardening</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text066-Care for Children" id="text066-Care for Children"><label for="text066-Care for Children">&nbsp;Care for Children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Washing" id="text066-Washing"><label for="text066-Washing">&nbsp;Washing</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Handiwork" id="text066-Handiwork"><label for="text066-Handiwork">&nbsp;Handiwork</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text066-Care for Older Children" id="text066-Care for Older Children"><label for="text066-Care for Older Children">&nbsp;Care for Older Children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Ironing" id="text066-Ironing"><label for="text066-Ironing">&nbsp;Ironing</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Driving" id="text066-Driving"><label for="text066-Driving">&nbsp;Driving</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text066-Care for Disabled Children" id="text066-Care for Disabled Children"><label for="text066-Care for Disabled Children">&nbsp;Care for Disabled Children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Shopping (Food/Grocery)" id="text066-Shopping (Food/Grocery)"><label for="text066-Shopping (Food/Grocery)">&nbsp;Shopping (Food/Grocery)</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Caring for Pets" id="text066-Caring for Pets"><label for="text066-Caring for Pets">&nbsp;Caring for Pets</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text066-Care for Elderly" id="text066-Care for Elderly"><label for="text066-Care for Elderly">&nbsp;Care for Elderly</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Cooking for Children" id="text066-Cooking for Children"><label for="text066-Cooking for Children">&nbsp;Cooking for Children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text066-Cooking for Family" id="text066-Cooking for Family"><label for="text066-Cooking for Family">&nbsp;Cooking for Family</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>Do You Have Any Experiences With Children?</td> <td> <fieldset> <table border="0" id="checkbox_table_text067-"> <tr> <td valign="top"><input type="checkbox" name="text067-Babysitting" id="text067-Babysitting"><label for="text067-Babysitting">&nbsp;Babysitting</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text067-Experience Caring for 2-5 old Children" id="text067-Experience Caring for 2-5 old Children"><label for="text067-Experience Caring for 2-5 old Children">&nbsp;Experience Caring for 2-5 old Children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text067-Worked at a summer camp" id="text067-Worked at a summer camp"><label for="text067-Worked at a summer camp">&nbsp;Worked at a summer camp</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text067-Worked with Childrenrsquos clubs" id="text067-Worked with Childrenrsquos clubs"><label for="text067-Worked with Childrenrsquos clubs">&nbsp;Worked with Children&rsquo;s clubs</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text067-Experience Caring for 6-10 old Children" id="text067-Experience Caring for 6-10 old Children"><label for="text067-Experience Caring for 6-10 old Children">&nbsp;Experience Caring for 6-10 old Children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text067-Worked at a school" id="text067-Worked at a school"><label for="text067-Worked at a school">&nbsp;Worked at a school</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text067-Previous Au Pair Experience" id="text067-Previous Au Pair Experience"><label for="text067-Previous Au Pair Experience">&nbsp;Previous Au Pair Experience</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text067-Experience Caring for 10+ old Children" id="text067-Experience Caring for 10+ old Children"><label for="text067-Experience Caring for 10+ old Children">&nbsp;Experience Caring for 10+ old Children</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text067-Voluntary work with Children" id="text067-Voluntary work with Children"><label for="text067-Voluntary work with Children">&nbsp;Voluntary work with Children</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text067-Experience Caring for Babies" id="text067-Experience Caring for Babies"><label for="text067-Experience Caring for Babies">&nbsp;Experience Caring for Babies</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text067-Worked in kindergarten" id="text067-Worked in kindergarten"><label for="text067-Worked in kindergarten">&nbsp;Worked in kindergarten</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>Childcare Qualification (if yes, specify)</td> <td> <input type="text" name="varchar022" id="varchar022" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Please Give Detail Of Childcare Experience (please provide as much information as you can)</td> <td> <textarea rows="5" cols="50" name="text068" id="text068"></textarea> </td> </tr> <tr> <td>Hobby</td> <td> <fieldset> <table border="0" id="checkbox_table_text052-"> <tr> <td valign="top"><input type="checkbox" name="text052-Cinema" id="text052-Cinema"><label for="text052-Cinema">&nbsp;Cinema</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Socialising With Friends" id="text052-Socialising With Friends"><label for="text052-Socialising With Friends">&nbsp;Socialising With Friends</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Playing Musical Instrument" id="text052-Playing Musical Instrument"><label for="text052-Playing Musical Instrument">&nbsp;Playing Musical Instrument</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text052-Playing Sport" id="text052-Playing Sport"><label for="text052-Playing Sport">&nbsp;Playing Sport</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Reading" id="text052-Reading"><label for="text052-Reading">&nbsp;Reading</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Cooking" id="text052-Cooking"><label for="text052-Cooking">&nbsp;Cooking</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text052-Watching Sport" id="text052-Watching Sport"><label for="text052-Watching Sport">&nbsp;Watching Sport</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Listening To Music" id="text052-Listening To Music"><label for="text052-Listening To Music">&nbsp;Listening To Music</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Walking/hiking" id="text052-Walking/hiking"><label for="text052-Walking/hiking">&nbsp;Walking/hiking</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text052-Craftwork" id="text052-Craftwork"><label for="text052-Craftwork">&nbsp;Craftwork</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Dancing" id="text052-Dancing"><label for="text052-Dancing">&nbsp;Dancing</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Computer/email/web" id="text052-Computer/email/web"><label for="text052-Computer/email/web">&nbsp;Computer/email/web</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text052-Watching TV" id="text052-Watching TV"><label for="text052-Watching TV">&nbsp;Watching TV</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Drawing/painting" id="text052-Drawing/painting"><label for="text052-Drawing/painting">&nbsp;Drawing/painting</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Theatre" id="text052-Theatre"><label for="text052-Theatre">&nbsp;Theatre</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text052-Photography" id="text052-Photography"><label for="text052-Photography">&nbsp;Photography</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text052-Pets/animals" id="text052-Pets/animals"><label for="text052-Pets/animals">&nbsp;Pets/animals</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>Do You Play Any Musical Instrument?</td> <td> <select name="text086"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>If Yes Please Specify (piano, violin, guitar, etc.)</td> <td> <input type="text" name="varchar023" id="varchar023" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>What Sports Do You Like To Play?</td> <td> <fieldset> <table border="0" id="checkbox_table_text087-"> <tr> <td valign="top"><input type="checkbox" name="text087-Volleyball" id="text087-Volleyball"><label for="text087-Volleyball">&nbsp;Volleyball</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Gymnastics" id="text087-Gymnastics"><label for="text087-Gymnastics">&nbsp;Gymnastics</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Roller Skating" id="text087-Roller Skating"><label for="text087-Roller Skating">&nbsp;Roller Skating</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text087-Aerobics" id="text087-Aerobics"><label for="text087-Aerobics">&nbsp;Aerobics</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Hill Walking" id="text087-Hill Walking"><label for="text087-Hill Walking">&nbsp;Hill Walking</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Running" id="text087-Running"><label for="text087-Running">&nbsp;Running</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text087-Badminton" id="text087-Badminton"><label for="text087-Badminton">&nbsp;Badminton</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Hockey" id="text087-Hockey"><label for="text087-Hockey">&nbsp;Hockey</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Squash" id="text087-Squash"><label for="text087-Squash">&nbsp;Squash</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text087-Basketball" id="text087-Basketball"><label for="text087-Basketball">&nbsp;Basketball</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Horse Riding" id="text087-Horse Riding"><label for="text087-Horse Riding">&nbsp;Horse Riding</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Swimming" id="text087-Swimming"><label for="text087-Swimming">&nbsp;Swimming</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text087-Cycling" id="text087-Cycling"><label for="text087-Cycling">&nbsp;Cycling</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Ice Skating" id="text087-Ice Skating"><label for="text087-Ice Skating">&nbsp;Ice Skating</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Table Tennis" id="text087-Table Tennis"><label for="text087-Table Tennis">&nbsp;Table Tennis</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text087-Football" id="text087-Football"><label for="text087-Football">&nbsp;Football</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Mountaineering" id="text087-Mountaineering"><label for="text087-Mountaineering">&nbsp;Mountaineering</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Tennis" id="text087-Tennis"><label for="text087-Tennis">&nbsp;Tennis</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text087-Gym (Weights/circuit training)" id="text087-Gym (Weights/circuit training)"><label for="text087-Gym (Weights/circuit training)">&nbsp;Gym (Weights/circuit training)</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text087-Roller Blading" id="text087-Roller Blading"><label for="text087-Roller Blading">&nbsp;Roller Blading</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>Can You Swim?</td> <td> <select name="text088"> <option value="">&nbsp; <option value="Strong swimmer" >Strong swimmer <option value="Average swimmer" >Average swimmer <option value="Weak swimmer" >Weak swimmer <option value="Can&rsquo;t swim" >Can&rsquo;t swim </select> </td> </tr> <tr> <td>Do You Have First Aid Training Or Experience?</td> <td> <select name="text089"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>What Do You Think About Your Personality?</td> <td> <fieldset> <table border="0" id="checkbox_table_text090-"> <tr> <td valign="top"><input type="checkbox" name="text090-Co-operative" id="text090-Co-operative"><label for="text090-Co-operative">&nbsp;Co-operative</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Talkative" id="text090-Talkative"><label for="text090-Talkative">&nbsp;Talkative</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Strict" id="text090-Strict"><label for="text090-Strict">&nbsp;Strict</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text090-Quiet" id="text090-Quiet"><label for="text090-Quiet">&nbsp;Quiet</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Like my own company" id="text090-Like my own company"><label for="text090-Like my own company">&nbsp;Like my own company</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Responsible" id="text090-Responsible"><label for="text090-Responsible">&nbsp;Responsible</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text090-Sociable" id="text090-Sociable"><label for="text090-Sociable">&nbsp;Sociable</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Caring" id="text090-Caring"><label for="text090-Caring">&nbsp;Caring</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Flexible" id="text090-Flexible"><label for="text090-Flexible">&nbsp;Flexible</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text090-Funny" id="text090-Funny"><label for="text090-Funny">&nbsp;Funny</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Independent" id="text090-Independent"><label for="text090-Independent">&nbsp;Independent</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Positive Attitude" id="text090-Positive Attitude"><label for="text090-Positive Attitude">&nbsp;Positive Attitude</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text090-Neat and tidy" id="text090-Neat and tidy"><label for="text090-Neat and tidy">&nbsp;Neat and tidy</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Uses initiative" id="text090-Uses initiative"><label for="text090-Uses initiative">&nbsp;Uses initiative</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Polite" id="text090-Polite"><label for="text090-Polite">&nbsp;Polite</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text090-Active" id="text090-Active"><label for="text090-Active">&nbsp;Active</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Motivated" id="text090-Motivated"><label for="text090-Motivated">&nbsp;Motivated</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Disciplined" id="text090-Disciplined"><label for="text090-Disciplined">&nbsp;Disciplined</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text090-Organiser" id="text090-Organiser"><label for="text090-Organiser">&nbsp;Organiser</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Sensitive" id="text090-Sensitive"><label for="text090-Sensitive">&nbsp;Sensitive</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Hard Working" id="text090-Hard Working"><label for="text090-Hard Working">&nbsp;Hard Working</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text090-Helpful" id="text090-Helpful"><label for="text090-Helpful">&nbsp;Helpful</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Warm hearted" id="text090-Warm hearted"><label for="text090-Warm hearted">&nbsp;Warm hearted</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text090-Friendly" id="text090-Friendly"><label for="text090-Friendly">&nbsp;Friendly</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>How Long Have You Been Away From Home Before (in months)</td> <td> <select name="text095"> <option value="">&nbsp; <option value="1" >1 <option value="2" >2 <option value="3" >3 <option value="4" >4 <option value="5" >5 <option value="6" >6 <option value="7" >7 <option value="8" >8 <option value="9" >9 <option value="10" >10 <option value="11" >11 <option value="12" >12 <option value="13" >13 <option value="14" >14 <option value="15" >15 <option value="16" >16 <option value="17" >17 <option value="18" >18 <option value="19" >19 <option value="20" >20 <option value="21" >21 <option value="22" >22 <option value="23" >23 <option value="24" >24 <option value="24+" >24+ </select> </td> </tr> <tr> <td>Does Your Family Support You In This Application?</td> <td> <select name="text096"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>List Any Previous Full-time Jobs</td> <td> <textarea rows="5" cols="50" name="text123" id="text123"></textarea> </td> </tr> <tr> <td>Do You Smoke?</td> <td> <select name="text097"> <option value="">&nbsp; <option value="Every day" >Every day <option value="Sometimes" >Sometimes <option value="Socially/Occasionally" >Socially/Occasionally <option value="Giving Up" >Giving Up <option value="No/Never" >No/Never </select> </td> </tr> <tr> <td>If Yes, Are You Prepared Not To Smoke In Your Family House?</td> <td> <select name="text098"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>Do You Like To Socialise?</td> <td> <select name="text099"> <option value="">&nbsp; <option value="Every day" >Every day <option value="A few times a week" >A few times a week <option value="Once/Twice a week" >Once/Twice a week <option value="When something good is happening" >When something good is happening <option value="Not often" >Not often </select> </td> </tr> <tr> <td>Do You Exercise?</td> <td> <select name="text100"> <option value="">&nbsp; <option value="Every day" >Every day <option value="A few times a week" >A few times a week <option value="Once/Twice a week" >Once/Twice a week <option value="When I feel I should" >When I feel I should <option value="Hardly Ever" >Hardly Ever </select> </td> </tr> <tr> <td>Any Special Diet Requirements (vegetarian, vegan)?</td> <td> <input type="text" name="varchar025" id="varchar025" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>If Vegetarian Are You Prepared To Handle Meat And Fish?</td> <td> <select name="text101"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>If Family Vegetarian - Will You Follow A Vegetarian Diet?</td> <td> <select name="text102"> <option value="">&nbsp; <option value="Yes" >Yes <option value="No" >No </select> </td> </tr> <tr> <td>Medical Conditions</td> <td> <fieldset> <table border="0" id="checkbox_table_text053-"> <tr> <td valign="top"><input type="checkbox" name="text053-Asthma" id="text053-Asthma"><label for="text053-Asthma">&nbsp;Asthma</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text053-Diabetes" id="text053-Diabetes"><label for="text053-Diabetes">&nbsp;Diabetes</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text053-Other" id="text053-Other"><label for="text053-Other">&nbsp;Other</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>If Other, Please Specify Condition</td> <td> <input type="text" name="varchar026" id="varchar026" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>All Allergies</td> <td> <fieldset> <table border="0" id="checkbox_table_text054-"> <tr> <td valign="top"><input type="checkbox" name="text054-Dairy" id="text054-Dairy"><label for="text054-Dairy">&nbsp;Dairy</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text054-Dust" id="text054-Dust"><label for="text054-Dust">&nbsp;Dust</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text054-Gluten" id="text054-Gluten"><label for="text054-Gluten">&nbsp;Gluten</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text054-Pets" id="text054-Pets"><label for="text054-Pets">&nbsp;Pets</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text054-Nuts" id="text054-Nuts"><label for="text054-Nuts">&nbsp;Nuts</label></td> <td width="25px">&nbsp;</td> <td valign="top"><input type="checkbox" name="text054-Other" id="text054-Other"><label for="text054-Other">&nbsp;Other</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>If Other, Please Specify Allergy</td> <td> <input type="text" name="varchar027" id="varchar027" size="40" maxlength="200" value=""> </td> </tr> <tr> <td>Other Information About Yourself (achievements etc.)</td> <td> <textarea rows="5" cols="50" name="text112" id="text112"></textarea> </td> </tr> <tr> <td>Have You Ever Had A Criminal Conviction?</td> <td> <fieldset> <table border="0" id="checkbox_table_text113-"> <tr> <td valign="top"><input type="checkbox" name="text113-Yes" id="text113-Yes"><label for="text113-Yes">&nbsp;Yes</label></td> <td width="25px">&nbsp;</td> </tr> <tr> <td valign="top"><input type="checkbox" name="text113-No" id="text113-No"><label for="text113-No">&nbsp;No</label></td> <td width="25px">&nbsp;</td> </tr> </table> </fieldset> </td> </tr> <tr> <td>If Yes, Please Give More Details</td> <td> <input type="text" name="varchar029" id="varchar029" size="40" maxlength="200" value=""> </td> </tr> 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