Assistant Enrollment Application
We want to make participation in the DAC-PAS program as easy and effortless as possible. That's why our website contains just about everything you need to effectively be a part of the DAC-PAS team. From forms to manuals, Medicaid information to web links, we hope you find what you're looking for. And, if you don't, please always feel free to contact us and we'll be more than happy to help in any way we can.

Print Versions             General Application: -PDF Format -MS Word       If you would prefer to print your application, complete it on paper, and mail or deliver it to us, please choose one of the applications and formats to the left. Otherwise, please scroll down to begin the onilne, electronic application.               Coeur d'Alene Application: -PDF Format -MS Word

PERSONAL INFO Experience References Competencies Submission     FIRST NAME: LAST NAME: ADDRESS 1: ADDRESS 2: -- CITY: STATE: ZIP: -- E-MAIL ADDRESS: --   PHONE: - - ALTERNATE PHONE: - - HOW MAY WE CONTACT YOU? Telephone E-Mail Postal Mail HOW DID YOU HEAR ABOUT DAC-PAS? (Select) Word of Mouth Internet Search Engine Newspaper Other -- ARE YOU 18 YEARS OF AGE OR OLDER? Yes No PLEASE TELL US ABOUT YOUR HOBBIES AND INTERESTS:               Personal     WORK EXPERIENCE References Competences Submission     -1. COMPANY / INDIVIDUAL: PHONE: - -     POSITION: DURAION:     DESCRIPTION: -2. COMPANY / INDIVIDUAL: PHONE: - -     POSITION: DURAION:     DESCRIPTION: -3. COMPANY / INDIVIDUAL: PHONE: - -     POSITION: DURAION:     DESCRIPTION:               Personal Experience     REFERENCES Competences Submission     -1. FIRST NAME: LAST NAME:     RELATIONSHIP: PHONE:   - - -2. FIRST NAME: LAST NAME:     RELATIONSHIP: PHONE:   - - -3. FIRST NAME: LAST NAME:     RELATIONSHIP: PHONE:   - -               Personal Experience References COMPETENCIES Submission     -1. ARE YOU A CNA?   Yes No -2. WOULD YOU BE ABLE TO ASSIST IN TRANSFERRING AN INDIVIDUAL WHO USES A WHEELCHAIR?   Yes No -3. PLEASE LIST ANY SKILLS YOU HAVE THAT WOULD BE BENEFICIAL TO THIS POSITION:   -4. PLEASE LIST ANY LIMITATIONS OR CONDITIONS OF EMPLOYMENT:   (i.e. hours of availabiliy, gender, etc.) -5. PLEASE INDICATE YOUR LEVEL OF COMFORT WITH THE FOLLOWING:   NO PERSONAL CARE   (housekeeping, laundry, shopping, transportation. Cooking) SOME PERSONAL CARE   (bathing, toileting (assist), dressing, mobility) COMPLETE CARE   (toileting, bowel program, catheter, feeding, etc.)                 Personal Experience References COMPETENCIES Submission     -1. HAVE YOU COMPLETED A CRIMINAL BACKGROUND CHECK IN THE LAST YEAR?   Yes No -2. DO YOU HAVE RELIABLE TRANSPORTATION?   Yes No -3. PLEASE INDICATE THE AREAS IN IDAHO IN WHICH YOU WOULD LIKE TO WORK:   MOSCOW-BASED LOCATIONS: Moscow Troy Potlatch Julietta Lewiston Orofino Other:   COEUR D'ALENE-BASED LOCATIONS: Couer d'Alene   St. Maries   Kellog   Hayden   Sandpoint   Bonners Ferry   Other:             -4. WHEN ARE YOU AVAILABLE TO WORK?   Full-Time Part-Time Weekends Emergency               Personal Experience References Competencies   SUBMISSION     BY CLICKING "SUBMIT," I HEREBY AUTHORIZE DAC TO RELEASE THIS INFORMATION FOR PURPOSES OF EMPLOYMENT. I CERTIFY THAT THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER AGREE THAT, IF I FIND OTHER EMPLOYMENT, I WILL NOTIFY DAC AS SOON AS POSSIBLE TO UPDATE FILES. OTHERWISE, I UNDERSTAND THAT MY APPLICATION WILL BE ACTIVE IN THE DAC DATABASE FOR SIX MONTHS. Once we receive this application, the information will be put in our registry and will be sent out in our monthly mailings to our customers and as requested. Most of the time, the potential employers will call you themselves. In some rare cases, DAC staff will call you for an interview with the employer. If an employer selects you, contacting DAC staff at your local office (see below) BEFORE you start to work is REQUIRED. You must make arrangements to complete paperwork BEFORE you start. If this is not done, you will notbe paid for any work done before paperwork is completed. Depending on your experience and whether or not you have a current background check, you may or may not be able to start on the same day you do paperwork. The fee for obtaining a background check is $48 or $10, depending on how long it has been. If you need a background check, you will make an appointment with Health and Welfare when you come into DAC to fill out paperwork. You will know when you can start work after meeting with DAC staff. Training is not a billable service for our Medicaid/Medicare customers, so if one of our customers asks you to come in for training, you need to know that you will not be paid for it. It is a federal regulation that two people cannot work and be paid for doing the same job at the same time. If two people have worked at the same time, neither person will get paid until the matter is resolved, by our customer.   --