Personal Assistant Application 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 authorize RAMP to perform a criminal background check on me, and to release the information on this form and the results of the criminal background check to consumers who are looking for a PA/IP so that they may consider hiring me. 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.