56-23-020 (02/16) Page 3 of 3
WORK REFERENCES: (Please – Do NOT leave the following section blank)
Please list your work experience, beginning with your most recent employment. Do not use family members as references. If you do not have work
references we can contact, please provide other references such as volunteer experience, babysitting, house cleaning, etc. We will contact the
people you list below. Please list two people you know personally whom we can contact as references. Please do not list family members.
Employer Name _____________________________________________________________________ Related Duties _____________________
Supervisor Name ___________________________________________________________________ Supervisor Phone _________________
Employment Dates _________________________________________________________________
Reason for Leaving ____________________________________________________________________________________________________
Employer Name _____________________________________________________________________ Related Duties _____________________
Supervisor Name ___________________________________________________________________ Supervisor Phone _________________
Employment Dates _________________________________________________________________
Reason for Leaving ____________________________________________________________________________________________________
Employer Name _____________________________________________________________________ Related Duties _____________________
Supervisor Name ___________________________________________________________________ Supervisor Phone _________________
Employment Dates _________________________________________________________________
Reason for Leaving ____________________________________________________________________________________________________
Please list two (2) people you know personally who we can contact as references. Please do not list family members.
1. Name ________________________________________________________________________ Home Phone ______________________
How do you know this person? _______________________________________________________ Work Phone _______________________
How long known? _____________________________________________________________________________________________________
2. Name _________________________________________________________________________ Home Phone ______________________
How do you know this person? _______________________________________________________ Work Phone: ______________________
How long known? _____________________________________________________________________________________________________
I certify that the above is true. I understand that any false information may eliminate me from enrollment on the IHSS Registry. I understand that
misrepresentation or omission of facts called for is cause for removal from the IHSS Registry. I understand that my name and phone number may be
placed on a list to be given to persons who are seeking assistance in their homes.
I understand that I am not an employee or Ventura County In-Home Supportive Services and that the In-Home Supportive Services consumer is my
employer.
Applicant Signature: _______________________________________________________________________ Date: ______________________
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