ROP APPLICATION

Directions: Please Print Legibly

Molina
Jessica
Alexandra
Name: __________________________________________

(Last)

(First)

05/04/14
____________________

(Middle)

Date

978 D St. Apt.C

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

California
Merced
95341
_______________________________________________________________________________

(City)

(209 ) 756-5033

(State)

(Telephone Number)

(Zip Code)

molina.jessica64@yahoo.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Laboratory Assistant
Skills and/or competencies which qualify you for this position:
Efiicient, precatious, responsible.
Work well with others and pay close attention to every detail.

Spanish
Languages spoken and/or written (other than English):___________________________________

Have you ever been convicted, pleaded guilty or no contest to a misdemeanor or felony?
No

Yes

If yes, explain:________________________________

Do you possess a valid California Drivers License?

No

Yes

_______________________
(Number)

RECORD OF EDUCATION

Name of School
High School

City/State

Merced High School

Course of
study or
major

Last year
completed

Did you
graduate?

Diploma
or degree

N/A

1 2 3 4

June 2014

Diploma

Merced, CA

College/
University

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Lifetime member of CSF (California Scholarship Federation)

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Anytime

After school

After school

After school

After school

After school

Anytime

RECORD OF EMPLOYMENT: (Begin with your most recent job)

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

$100
Baby-sitter
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Take care of 3 children from 7:00 A.M. to 3:30 P.M.

_________________________________________________

To:

06/14
______

Present
______

Mo / Yr

Mo/Yr

6
2
Total ____Yrs.
________Mo.

2355 Pacheco Dr.

42 1/2h
Hours Per Week:_________
Reason For Leaving:

From:

Diego Molina

Merced, CA 95340

_________________________________________________

Cell: (209)756-8367

Supervisors Name:
Diego Molina
_____________________________________________________

_________________________________________________

Title__________________________Last Salary: _____________

_________________________________________________

Duties:

_________________________________________________

To:

______

______

Mo/ Yr

Mo/Yr

Total ____Yrs. ________Mo.

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

_________________________________________________
_________________________________________________
Supervisors Name:
________________________________________________

From:

To:

______

______

Mo /Yr

Mo/Yr

Title___________________________Last Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Total ____Yrs. ________Mo.

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

_________________________________________________

Supervisors Name:
________________________________________________

_________________________________________________

REFERENCES: Give the names of three persons not related to you.

Name
1.

Portia Mira

Complete Address (Include City, State, Zip)

Phone

Occupation_______

3752 Chukar Ct.

Merced, CA 95340

(209)819-0552

Graduate Teaching A

________________________________________________________________________________________________________________________________
2. Robb

Bartenslager

8499 Forest Hill Blvd.

(561)304-1000

Science Teacher

Wellington Fl. 33411

________________________________________________________________________________________________________________________________
3.

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

I understand that misrepresentation or omission of facts is cause for dismissal.

Date:_________________________Signature:_________________________________________________________________

N:\ROP\Charlotte Klock\ROP Forms\Forms\ROP Job Application with availbility back-for fillable.rtf

Revised 7/10