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Inland Regional Center

info@inlandrc.org

1365 S. Waterman Ave., San Bernardino, CA, 92408, US

DAY SERVICES ORIENTATION APPLICATION

Applicant

Applicant Name

Address

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

Experience Providing Services or Direct Supervision to Individuals with Developmental Disabilities

Time Employed

Company Address

Time Employed

Company Address

Education (Most recent first)

School Address

Dates Attended

School Address

Dates Attended

School Address

Dates Attended

Professional References

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

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

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

Choose how to sign