Section 1 of 5 in this document

DAY SERVICES ORIENTATION APPLICATION

Applicant

Applicant Name

Address

Please attach a copy of your identification, as well as your professional resume for review

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Section 2 of 5 in this document

Experience Providing Services or Direct Supervision to Individuals with Developmental Disabilities

Time Employed

Company Address

Time Employed

Company Address

Section 3 of 5 in this document

Education (Most recent first)

School Address

Dates Attended

School Address

Dates Attended

School Address

Dates Attended

Section 4 of 5 in this document

Professional References

Please attach 3 reference letters, must include contact information and be signed.

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What type of Day Service are you Interested in Providing? (Check all that apply)

Have you ever been vendored by IRC or another regional center?

Please attach a copy of your most recent Quality Assurance Evaluation

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Applicants applying for Day Services Orientation who are currently vendored providers for IRC or any regional center, must have services in good standing.

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