Please be aware that this is NOT an application for employment. You must fill out this form if you would like to have your name placed on our PA/IP Referral List which is shared with consumers who hire and maintain PA/IP’s. Wages for Personal Assistants/Individual Providers are paid through the Division of Rehabilitation Services (DRS) and/or the individual requiring assistance.

Filling out the below information is REQUIRED. You must also attend a mandatory orientation session and provide copy of ss card and photo ID with current address before your name is added to the Statewide PA/IP Referral List. (Information required, for RAMP staff to complete a background check, and orientation eligibility)

Contact Information:

Gender:MaleFemaleBothOtherNot Specified

Previous Address (If at current address less than 2 years):

Have you ever been convicted of a criminal violation?YesNo

Please read carefully
I understand that RAMP publishes a link to their PA/IP Referral List on the RAMP website and that my contact information will be available on there if my name is added to the Referral List. I understand that completing the program requirements does not mean that I will be hired as a PA/IP by a consumer. I understand that if I am hired as a PA/IP by a program participant that I will NOT be an employee of RAMP. I understand that yelling, cursing or being disrespectful to RAMP staff or consumers will get me removed from the RAMP PA/IP Referral List.