Application Form 2010 General Application Form



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Application Form 2010


General Application Form

All the information should be filled out with capital letter using Microsoft word



To fill out the box  please click the box twice, then choose checked on default value then click ok.


Basic Personal Information

Family name




First name

CAROLINA

Place and Date of birth

SURABAYA/28/JUNE/1984 (dd / mm / yyyy)

Age

25

Nationality

INDONESIAN

Gender

 Female  Male

Civil status

(please select the most appropriate, can be more than 1)

 Single

 Married

 Divorced

 Living with parents

 Living on your own

 Living with partner



Home telephone number (please add area & country code)




Mobile phone number




E-mail address




MSN / Yahoo messenger account




Street / number




Postal (ZIP) code




City




Province / Region




Country




Passport number




Date of issuing




City of issuing




Earliest start date *It will take approximately 2- 8 months for an au pair to be placed and arrive in the Netherlands after receiving a complete and correct file.



Continue of general application form

Additional personal information


Religion

CHRISTIAN

Are you active in practicing your religion?

Yes None. Specify: GO TO THE CHURCH, BECOME A YOUTH CHRISTIAN MEMBER

Do you have any special religious faith needs?

Yes None. Specify:

Family size

(cross the one which is not suitable for you)

…X…brother(s) & …X.. sister(s) older

…X...brother(s) & 1 sister(s) younger



Occupation of father

OPERATIONAL STAFF

Occupation of mother

HOUSEWIFE

Have you ever been away from your family other than holidays? Where?

YES. JAKARTA

Have you ever been in other countries?

Which ones? What were the reasons?



NO

Have you travelled inside your own country?

 Yes  No

 Often


 Seldom

Do you know anyone/ do you have any relatives who live in the Netherlands or in other European countries (outside your home country)? If you do, what is your relation with this person?


Yes None. Specify:

JOSE RIZAL BATARA GOA, FRIEND, STAY AT AMSTERDAM FOR 7 YEARS

VEVE CHU, FRIEND, STAY AT ROTTERDAM WITH HER HUSBAND

LINASARI SUNYOTO, FRIEND, STAY AT ITALY FOR 1 YEAR



Where did you grow up?

 City

 Town/ small city

 Village/ country side


Where do you live now?

 City

 Town/ small city



 Village/ country side

Diet

 No  Yes. Specify: ………

Allergies

 No  Yes. Specify:PRAWN, CRAB

Smoking

 No  Yes on occasions only

Do you understand if you are a smoker you are not allowed to smoke near the children nor inside the house?

 No  Yes

Continue of general application form




Have you ever been arrested for a violation?

 No  Yes. Specify: ……

Name your interests and hobbies?

TEACHING, BACKPACKING, BLOGGING, WRITING SOME EDUCATION JOURNALS,SHOPPING

Do you play any instruments?


NO

Do you have any specials talents?

I LOVE TEACHING AND WRITING

What type of sports do you do?

SWIMMING, VOLLEYBALL, BIKING

Do you have any tattoos?

 No  Yes. Specify: ……

Do you have any piercing?

 No  Yes. Specify:ONLY FOR EARING

Do you use make up?

 No  Yes. Specify: BLUSH ON, EYE SHADOW

How do you describe your dressing style?

SIMPLE, ELEGANT AND COMFORTABLE

Do you have a boyfriend? If you do, does he live in your home country or abroad?

 No  Yes. He lives in: …….



Education

Education / course

Name of institute

Start year

End year

Diploma

ELEMENTARY SCHOOL

SD KATOLIK RA. KARTINI


1990

1996

Yes No

JUNIOR HIGH SCHOOL

SMP KATOLIK SANTO CAROLUS BORROMEUS

1996

1999

Yes No

HIGH SCHOOL

SMU KATOLIK SANTA MARIA

1999

2002

Yes No

COLLEGE

SURABAYA UNIVERSITY

2002

2006

Yes No



Skills

English (according to the English certificate)

 Native

Fluent

Good

Moderate

 Poor

 None

Spanish


 Native

Fluent

Good

Moderate

 Poor

 None

Afrikaans

 Native

Fluent

Good

Moderate

 Poor

 None

Dutch

 Native

Fluent

Good

Moderate

 Poor

 None

German

 Native

Fluent

Good

Moderate

 Poor

 None

French

 Native

Fluent

Good

Moderate

 Poor

 None

Other …………..

 Native

Fluent

Good

Moderate

 Poor

 None

Other …………..


 Native

Fluent

Good

Moderate

 Poor

 None

Drivers license

No  Yes. Since 28/JUNE/2006

Continue of general application form




Do you have international driving license?

No  Yes. Since …/… .. / ….



General Working experience

Employer

Job description

Hours per week

Start date

End date

Reference included

SURABAYA UNIVERSITY

ADMINISTRATOR (PART TIMER)

3 HR/WEEK

1 JANUARY 2005

1

JULY 2005



Yes No

CIPUTRA UNIVERSITY

STUDENT ADVISOR AND ADMINISTRATOR

40 HR/WEEK

1 FEBRUARY

2007


PRESENT

Yes No

PELITA PERMAI KINDERGARTEN

TEACHER & VOLUNTEER FOR POOR CHILDREN

5 HR/WEEK

1 AUGUST 2009

PRESENT

Yes No



Household Working Experience

Household working experience

Specify Experience. Give examples with what you have done in each household activities

Ironing clothes

Yes  No

I DO IRONING EVERYDAY AT MY HOME BECAUSE I NEVER HAVE A MAID

Washing and folding clothes

Yes  No

YES, FOR WASHING AND FOLDING CLOTHES I DO THIRD A WEEK AND I DO BY MY SELF MANUALLY OR AUTOMATICALLY

Vacuuming

Yes  No

I ALWAYS DO IT TWICE A WEEK AND I CAN ENJOY TO DO IT BY MY SELF

Simple cooking


Yes  No

I LIKE COOKING ANYWAY. FOR EXAMPLE INDONESIAN FOOD (FRIED RICE, TOFU SOUP)MACARONI, SPAGHETTY AND OMELETTE

Advanced cooking

Yes  No




Cleaning

Yes  No

FOR CLEANING, I DO EVERYDAY BEFORE I GO TO THE OFFICE

Take care of pets

Yes  No

FOR SURE. I HAVE 2 DOGS AND TAKE CARE OF THEM

Do you have any experience with the electric equipment below?

Continue of general application form




Microwave

Yes  No

Washing machine

Yes  No

Dish washer

Yes  No

Oven

Yes  No MANUALLY

Electric stove

Yes  No

Gas stove


Yes  No

Vacuum Cleaner

Yes  No

How do you describe your housekeeping style?

 easy  casual  neat  very neat & organized



Personality

Please circle your best 5 characteristics.

 Decisiveness

 Sensitivity

 Humble

 Tolerance

 Calm

 Nervousness

 Adaptability

 Empathy

 Emotional management

 Rule acceptance

 Dynamic

 Likes routine

 Dominance

 Artistic

 Intellectual

 Team player

 Planner

 Creative

 Independent mindedness


 Ambitious

 Sociable


 Organized

 Talkative

 Insight to people

 Conscientious/ reliable

 Social comfort














From the 5 characteristics you mentioned above, what is the strongest one?

ADAPTABILITY

Please mention your 3 personal qualities.

  1. CARING

  2. PATIENC E

  3. PLANNER & ORGANIZED

Continue of general application form




Please mention 3 things that you can improve.


  1. TEAM PLAYER

  2. CREATIVE

  3. MORE KNOWLEDGE ABOUT CHARACTER OF CHILDREN

Give an example of a difficult situation that you experienced? How did you solve it?

ONE OF MY STUDENT HAVE A SINGLE PARENT WHO LOST HER MEMORY AND LET THE CHILD SINCE SHE WAS 3 YEARS OLD. AS A RESULT, THE CHILD IS DIFFICULT TO CONCENTRATE WHEN STUDYING AND NEED TIME TO DIGEST THE LESSONS WITHIN. I REGULARLY ASSIST HER, MOTIVATE HER AND DEVELOPED HER SELF IDENTITY. AT PRESENT, THE CHILD (7 YEARS OLD) SHOWED A SIGNIFICANT LEARNING ABILITIES.


Give an example of your greatest achievement you have experienced in your life?

BE A TEACHER FOR POOR CHILDREN MAKE ME ALWAYS THANK TO GOD ABOUT MY LIFE AND FOR THEM.I HAVE LEARNED MANY THINGS. BESIDES, I LOVE WRITING SO THAT MY RECTOR GIVE ME SOME CHANCES FOR MAKE A JOURNAL AND FOLLOW THE LOCAL RESEARCH CHAMPIONSHIP, I GOT SECOND WINNER.



Motivation

What cities do you want to visit in Europe or the Netherlands?

1.AMSTERDAM

2.FRANCE


3.GREEK

Why will you be an excellent candidate?

(Make a short statement)

I’D LIKE TO BE AN EXCELLENT CANDIDATE BECAUSE I HAVE A BIG INTEREST AND PASSION WHEN I MEET THE CHILDREN WHO HAVE A SPIRIT AND PURITY. I LOVE CHILDREN. THEY ARE SO CUTE, VERY FUN AND SO NICE. I ALWAYS LAUGH DURING I SPEND MY TIME WITH THEM. I THINK CHILDREN HAVE GOOD UNIQUE CHARACTERISTIC WHICH MAKE ME ALWAYS LOVE THEM. I AM PATIENT, POLITE, ADAPTABLE,AND CARING. YOU CAN COUNT ON ME.

How will you adjust to a new family, new country and new culture?

I AM A EASY GOING GIRL, I CAN ADAPT FASTER AND I JUST BELIEVE THAT A NEW CONDITION (NEW FAMILY, NEW CULTURE IN A NEW COUNTRY) WILL BE GIVE ME MORE SOME INTERESTING EXPERIENCE. I AM SURE THAT I CAN DO THE BEST FOR MY HOST FAMILY AND MY SELF.

What problems or challenges do you expect to encounter? How will you manage?


FACED THE ART OF TAKING CARE CHILDREN IN EUROPE. I THINK IT IS VERY DIFFERENT CONDITION BETWEEN EUROPE CULTURE AND ASIAN (INDONESIAN) CULTURE

If after a few weeks you find the position is not working out how would you deal with it ?

I TRY TO COMMUNICATE IT WISELY WITH MY HOST FAMILY AND MY AGENT AND FIND THE WIN-WIN SOLUTION FOR BOTH.

What type of relationship would you like to have with your host family ?

FEEL COMFORTABLE, HAVE FUN, HUMOUR,TREAT ME AS THEIR FAMILY AND SO DO I.

How are you going to spend your free time in the Netherlands?

HANGING OUT AROUND CITY WITH MY FRIEND AND VISIT SOME MUSEUM FOR SIGHT SEEING

What are your future plans after finishing the placement program?

BEING A TEACHER AND DESIGNER CURRICULUM FOR POOR CHILDREN’S SCHOOL IN MY CITY

What will you do/be after 5 years?

DEVELOPED A LITTLE SCHOOL FOR POOR CHILDREN IN MY CITY

What are your personal goals to achieve in your year in the Netherlands?

IMPROVE MY LANGUAGE SKILLS (DUTCH AND ENGLISH) PROPERLY AND DEVELOPED MY KNOWLEDGE ABOUT CHILD STUDIES

If you are only interested in Domestic au pair (household care) program , this is the end of the general application form.

 Yes, I am only interested in the domestic au pair program.

Please continue with writing a motivation letter and making a photo book

 No, I am interested in another program.


Please continue with filling out other appendixes

Hereby I declare that all information I gave is correct.

Surabaya, 19th January 2010

Carolina


_______________________________________

(Candidate’s Full Name)

Hereby I send the complete general application form including 3 pages of appendix.

To fill out the box  please click the box twice, then choose checked on default value then click ok.

Please enter all the information using Microsoft Word

Please click on your preferred program:

 Interested in childcare program ( au pair)

Go to form A childcare working experience

 Interested in elderly care (non medical) program (au pair)



Go to form B elderly care working experience



Form A - Childcare Working Experience

Family / institute name

Number of children

Age range of children

Hours per week

Start date

dd/mm/yyyy



End date

dd/mm/yyyy



Reference included

PELITA PERMAI KINDERGARTEN

35

 Baby; 0 – 1 years old

 Toddler; 1 – 3 years old

 Elementary; 4 – 8 years old

 Elementary; 9 and up


5 HR/WEEK

1 AUGUST 2009

PRESENT

Yes No

SULAMI/MY AUNT

1

 Baby; 0 – 1 years old

 Toddler; 1 – 3 years old

 Elementary; 4 – 8 years old

 Elementary; 9 and up



3 HR/DAY

26 OKTOBER 2006

PRESENT

Yes No







 Baby; 0 – 1 years old

 Toddler; 1 – 3 years old

 Elementary; 4 – 8 years old

 Elementary; 9 and up












Yes No







 Baby; 0 – 1 years old

 Toddler; 1 – 3 years old

 Elementary; 4 – 8 years old

 Elementary; 9 and up












Yes No

Childcare Activities


Specify Experience. Give examples with what you did in each childcare activities

Changing diapers

 Yes  No

I DO THE SAME WHEN MY AUNT HAVE A BABY. CHANGING DIAPERS WHEN THEY’RE NOT AT HOME

Feeding babies

 Yes  No




Bathing babies

 Yes  No




Playing with children

 Yes  No

YES, I DO. PLAYING WITH CHILDREN IS A GREAT TIME. I DO THE SAME WITH THE POOR CHILDREN AT PELITA PERMAI KINDERGARTEN AND MY COUSIN.

Cooking for children

 Yes  No

SOMETIME, I COOK FOR A SIMPLE FOOD. FOR EXAMPLE SPAGHETTY, OMMELETE.

Feeding the children

 Yes  No

FEEDING THE POOR CHILDREN AT LUNCH TIME

Getting children up and dressed

 Yes  No




Bath the children

 Yes  No




Picking up after the children

 Yes  No





Washing, ironing children’s clothes

 Yes  No

I WILL DO IT IF THE FAMILY ASK FOR TO DO THAT

Making the beds of the children

 Yes  No




Bringing children to bed

 Yes  No

USUALLY I READ SOME STORY BEFORE MY COUSIN GOING TO SLEEP

Picking the children up from school

 Yes  No




Help children with homework

 Yes  No

HELP THE POOR CHILDREN TO FINISHED THEIR HOMEWORK AND TEACH THEM ABOUT SOMETHING ELSE

What do you like most about taking care of children?

PLAYING WITH THEM BECAUSE WE GOT A GREAT TIME AND WE CAN DO ANYTHING TO LEARN SOMETHING.

What do you like least about taking care of children?

FEEDING THEM BECAUSE SOMETIMES THEY REFUSE THE FOOD ESPECIALLY VEGETABLE AND WASTE A TIME WITH THEIR TOYS BUT I’M PRETTY SURE, I HAVE FUN IDEA FOR THEM MORE LIKELY TO EAT VEGGIES OR ANOTHER FOOD

What type of activities would you plan for

a) 3 year old girl

b) 6 year old boy

c) 6 month old baby

d) 9 year old boy or girl


A. 3 Y.O  I AM GOING TO PLAYING AND DRESS UP A DOLL, MAKE SOME INTEREST STORY, PLACE THE COLOURFULL WOODEN LETTER AND SPELL THE WORD, WATCHING CARTOON MUSICAL FILM AND SINGING TOGETHER

B. 6 Y.O  I AM GOING TO PLAYING BOOM BOOM CAR WITH HIM, CREATE HIS FAVOURITE ROBOT, SPELL THE ALPHABET, PLAY WITH THE VOCABULARY,SINGING TOGETHER, HANGING OUT TO THE ZOO

C. 6 MONTH  MAKE SOME FUNNY EXPRESSION, GIVE HER A COLOURFULL BALL FOR IMPRESS HER ABOUT COLOUR, PLAYING WITH A DOLL, LISTENING BEETHOVEN OR INSTRUMENTAL MUSIC FOR DEVELOPED HER BRAIN AND INTRODUCE ABOUT THE MUSIC

D. 9 Y.O  PLAYING HIDE AND SEEK, BUILD A BARN BLOCKS, SINGING TOGETHER, DRAWING, READING THE STORY, BIKING, GOING TO SUPERMARKET FOR SHOPPING AND INTRODUCE HER/HIM ABOUT THE KIND OF PRODUCT.



How will you discipline the children?

FIRST, I WILL PERSISTENT TO BEHAVE WITH MY SELF BECAUSE IT WILL HELP TO DETERMINE HOW THE CHILDREN IS GOING TO BEHAVE. SECOND, I WILL GIVE THE ARGUE IF THE CHILDREN DOING SOME MISTAKES WITHOUT YELLING AND SCREAMING. THIRD, I WILL GIVE SOME REWARDS AND PRAISE FOR GOOD BEHAVIOUR

How will you handle a child that refuses to eat?

I THINK HER BODY WILL TELL HER WHEN HE NEEDS TO EAT SO THAT I WILL OFFER HER NUTRITIOUS MEALS OR SNACKS. IF THE CHILD NOT INTEREST IN WHAT IS BEING OFFERED, I WILL END THE MEAL AND TRY TO TELL HER THAT SHE CAN CONTINUE TO REFUSE TO EAT OR EAT WHENEVER SHE WANTS.

Can you tell about a time when you have been aware of children in an unsafe environment and what did you do about it.


WHEN HE START TO PLAYS WITH THE DANGEROUS STUFF OR IN A DANGEROUS AREA/GROUND PLAYING (E.G: FURNITURE OR TOYS WITH PAINT)

I WILL SET A POSITION SAFELY FOR GATES TO BLOCK ACCESS TO STAIRS AND OTHER DANGEROUS AREAS, KEEP THE WINDOW CLOSED, REMOVE ALL DANGEROUS THINGS, KEEP ALL MEDICINES OR MAKE SURE THE TOY BOX HAS VENTILATION HOLES





Smiling Faces Au Pairs

Nicolaas Zasstraat 43A, 3033 TC , Rotterdam, The Netherlands, Chamber of Commerce 24396534,

agents@smilingfaces.nl, www.smilingsfacesaupairs.com

tel : 0031-10-4659797





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