Personal Assistant Training Course Application


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The following information must be completed in full or your application may be disregarded.

Employment History: Please list most recent first

Personal References: Please list 2 non-relative

I authorize IMPACT CIL. to release this application and/or certification and training information to consumers of IMPACT's Personal Assistant Program for the specific purpose of considering my application for employment. I also understand that I have the right to inspect the material which is being released.

I understand that when I complete the Personal Assistant Training, whether it is one-on-one or group training, I am authorizing IMPACT CIL. to give my name and Social Security Number to the Division of Rehabilitation Home Services Program for their use in tracking the actual employment of trained Personal Assistants.

I understand that this application and initial interview does not guarantee that I will be selected to participate in the Personal Assistant Program or that I will be hired as a Personal Assistant. I understand that if I am hired as a Personal Assistant, I will not be an employee of IMPACT CIL.

I, the undersigned, acknowledge that all the information that I have given on this Personal Assistant application is true and accurate to the best of my knowledge.

Personal Assistant Areas of Work


Alton/GodfreyBethalto/Cottage Hills/MoroCollinsville/Maryville/TroyEdwardsville/Glen CarbonGranite City/Madison/VeniceBond CountyWood River/East Alton/Harford/Roxana/South RoxanaCalhoun CountyGreene CountyJersey CountyMacoupin CountyRural Madison CountySt. Clair County

Personal Assistant Questionaire

Please answer all questions, even if you are unsure about the correct response.


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Your employerThe doctorYour employers parents


Answer the phoneNot answer the phoneYou employer makes the decision


The personal assistantThe employer


A crippled personA person with a disability