Instructions:

Must be 18 years or older to apply.

If you already have an IHSS recipient that you are working for, this is NOT the process to enroll as their IHSS provider – go here for enrollment instructions.

If you are seeking work and would like to join our Registry of providers who are referred out to IHSS recipients who need care, please complete all areas of this application. Only submit one application. If you made a mistake, would like to update any of your information, or check the status of your application please contact us directly at RegRecruitment@placer.ca.gov.

Registry Provider Application:

SECTION ONE

First Name:

Middle Initial:

Last Name:

Other Name:

Phone:

Other Phone:

Primary Email Address:

Mailing Address:

Street:

City:

State:

Zip Code:

Physical Address:

Same as Mailing Address

Street:

City:

State:

Zip Code:

SSN Number:

Date of Birth:

Gender:

Nationality:

Driver License # Or California ID:

Exp Date:

Emergency Contact:

Name:

Relationship:

Phone Number:

Personal References:

SECTION FIVE

THE FOLLOWING REFERENCE SECTION MUST BE COMPLETED EVEN IF ATTACHING A RESUME.
By providing references below, you are giving permission for the Placer County Public Authority to obtain information regarding your prior work history. We highly recommend that you reach out to your references to inform them that they will be contacted by the Public Authority for this purpose. The Public Authority must be able to contact and verify references for you to move forward in the Registry Provider application process.

Personal References – TWO ARE REQUIRED (Please DO NOT use relatives):

Click to add more references

Full Name:

Relationship:

Address:

Phone #:

Years Acquainted:

Email Address:

Work References:

SECTION SIX

Please provide 3 WORK REFERENCES – Begin with most recent job (Please DO NOT use relatives):

Click to add more references

Job Title:

Employer:

Address:

Contact Name:

Contact Phone #:

Contact Email:

Start Date:

End Date:

Total Yr & Mo:

Hours/Week:

Reason for Leaving:

Duties

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Imported: Registry Provider Application

Registry Provider Application:

Preferences:

Availability:

Location

Personal References:

Work References:

Referral Source