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IHSS Registry Provider Application

Steps

  1. 1. PERSONAL INFORMATION
  2. 2. WORK PREFERENCES
  3. 3. WORK EXPERIENCE & SKILLS
  4. 4. PERSONAL REFERENCES
  5. 5. PROVIDER ENROLLMENT AGREEMENT
  6. 6. CERTIFICATION & DISCLOSURE
  • PERSONAL INFORMATION

    1. Sample Text

    2. IHSS Public Authority Registry Providers must update their status every month:*

      How would you prefer to be contacted? Check all that apply.

    3. Photo I.D. and Social Security card are required.*

      Please check the box:

    4. Form of Transportation:*

      Do you plan to use your own vehicle to transport clients?

    5. Do you have auto insurance?*

    6. How did you hear about being on the Registry?*

      Check all that apply.