All applicants to the Public Authority Registry will be required to undergo a Department of Justice Criminal Background Investigation to determine if the applicant has ever been convicted of certain violations of the Penal Code. Applicants who do not “clear” the DOJ check will not be listed on the Registry. The cost for fingerprinting is the applicant’s responsibility (the cost is approximately $70).

Note: An incomplete application will delay processing

Printable PDFs

Registry Provider Application

Release of Information Consent

Personal Information

Name(Required)

Address(Required)

Street Address Address Line 2 City ZIP Code

Home Phone(Required)

Cell Phone

Social Security Number(Required)

Birthdate(Required)

Gender(Required)

Male

Female

Prefer Not to Answer

Email(Required)

Enter Email Confirm Email

Work Experience

How many years of experience providing In-Home care do you have?(Required)

Explain your experience providing in-Home care(Required)

Are you now or have you ever been employed by (IHSS) In-Home Supportive Services?(Required)

Yes

Work References

Please list three work references that show a continuous and consistent employment history of at least six months each. Make sure to provide names and valid phone numbers of people we can reach and talk to concerning your work.

Please do not list family members as your references

Work Reference 1

Employer or Client Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

First Last

Ok to contact

Yes

Work Reference 2

Employer or Client Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

First Last

Ok to contact

Yes

Work Reference 3

Employer or Client Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

First Last

Ok to contact

Yes

Personal References

Please list two names of people who know you personally whom we can contact as character references. Personal References must be different from Work References.

Please do not list family members.

Personal Reference 1

Name(Required)

First Last

Phone(Required)

How do you know?(Required)

How Long?

Years

Months

Personal Reference 2

Name

First Last

Phone

How do you know?

How Long?

Years

Months

Optional Questions

The following questions are Optional (not required). The information will be kept confidential and used only by staff for statistical purposes and to improve opportunities for care providers.

Do you have health Insurance?

Medi-Cal

None

Other

Ethnicity:

African American

Asian-Pacific Islands

Caucasian

Native American

Latino

Other

Other Ethnicity

Consent(Required)

I certify that the information on this application is true.

I understand that any false information may eliminate me from consideration. I understand that being accepted to the Contra Costa IHSS Public Authority Registry means my name may be included on lists given to persons who are seeking assistance in their homes.

I understand that the information on this application may also be shared with prospective employers. I also understand that my employer is not Contra Costa In-Home Services Public Authority (IHSS). The IHSS client is my employer. I understand that I am responsible for paying the fees associated with the Criminal Background Investigation (CBI).

I further understand that passing CBI does not guarantee employment. I also understand that the Public Authority DOES NOT guarantee employment. The Public Authority is a referral service for consumers and providers; it is not an employment agency.

Release of Information Consent(Required)

I give permission for the Contra Costa County IHSS Public Authority to obtain information regarding my work history.

I understand this release of information consent is valid for 90 days from the date indicated below.

Name(Required)

First Last

Signature

Date(Required)

Name

This field is for validation purposes and should be left unchanged.

Registry Provider Application Form

Note: An incomplete application will delay processing

Printable PDFs

Personal Information

Desired Work Schedule

Tell us about you

IHSS Authorized Tasks

Specialized Tasks

Preferred Clients

Language

Other information

Licenses, Certificates and Trainings

Work Experience

Work References

Work Reference 1

Work Reference 2

Work Reference 3

Personal References

Personal Reference 1

Personal Reference 2

Optional Questions