PA Marin Registry Provider Application
PA Marin does not discriminate on the basis of sex, race, color, religion, age, sexual orientation, disability, marital status, national origin, citizenship status, genetic information, gender identity and expression, AIDS/HIV, medical condition, political affiliation, or military or veteran status in employment or in its educational programs and activities.
Privacy Policy Disclaimer
Confidentiality is our top priority. The personal information collected is only used by IHSS Public Authority for employment purposes. We do not share your information with any third parties.

We will not, in any circumstances, share your personal information with other individuals or organizations without your permission, including public organizations, corporations or individuals, except when applicable by law. We do not sell, communicate or divulge your information to any mailing lists. We can offer to add your contact information to our newsletter and employee updates list. In this last case, you may at any time ask us to remove your name from such lists.
Full Name *
Email Address *
Address *
Phone number *
Do you authorize the Public Authority to communicate to you via text? (Msg & Data rates may apply) *
Date of Birth *
MM
/
DD
/
YYYY
Are you authorized to work in the United States? *
Gender *
Do you have experience as an in-home caregiver? *
If yes to question above, how many years of caregiving experience?
Have you ever completed the state mandated IHSS Enrollment Process, including fingerprints? *
If yes to the question above, how long ago was the IHSS Enrollment Process?
List any training (and date of training, if possible) you have had related to in-home care:
List any certificates or licenses you possess (current or expired, even if from other countries)
Any additional skills that you would like us to be aware of?
What is the best time to reach you? *
A representative from PA Marin will contact you shortly! If you have any further questions, please give us a call at (415) 499-1024 or email us at registry@pa-marin.org.
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