ROP APPLICATION

Directions: Please Print Legibly

Thao
Jenny
Name: __________________________________________

(Last)

(First)

5/5/2014
____________________

(Middle)

Date

973 Maple Ave.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95341
_______________________________________________________________________________

(City)

(209 ) 201-7853

(State)

(Telephone Number)

(Zip Code)

)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Nursing Aide
Skills and/or competencies which qualify you for this position:
CPR and BLS certified, completed Blood Bourne Pathogens, obtained HIPAA privacy compliance, perform
basic vital signs assessment, basic pharmacolgy, bilingual, First Aid

Hmong
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

General

1 2 3 4

Pending
June 2014

General

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:
Volleyball-Libero, Leo Club-member, Kiwins Club-member, Link Crew member, Asian Club- President

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

8am-8pm

10am-8pm

10am-8pm

10am-8pm

10am-8pm

10am-8pm

8am-12pm

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

Period of Employment
From:

Company Name, Address, and Phone Number

Volunteer
Nursing Aide
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Perform vital signs, filing, schedule patients,

shadowing nurses

_________________________________________________

To:

2/2014
______

Current
______

Mo / Yr

Mo/Yr

5
Total ____Yrs. ________Mo.
5
Hours Per Week:_________
Reason For Leaving:

From:

Job Title and Duties Performed

1260 North D St.

Current
______

Mo/ Yr

Mo/Yr

10
Total ____Yrs. ________Mo.

Merced, CA

_________________________________________________
Supervisors Name:
Sonia Willson
_____________________________________________________

_________________________________________________

Volunteer
Title__________________________Last
Salary: _____________
Link Crew

_________________________________________________

Duties:

_________________________________________________

Tutor students,

_________________________________________________

To:

8/2013
______

Mercy Medical Center

Merced Union High School

205 W. Olive Ave.
Merced, CA

Hours Per Week:_________

3
Reason For Leaving:

_________________________________________________
_________________________________________________
Supervisors Name:
Marcia-Marie L. Rosson
________________________________________________

From:

To:

6/2012
______

8/2013
______

Mo /Yr

Mo/Yr

1
3
Total ____Yrs.
________Mo.
5
Hours Per Week:_________
Reason For Leaving:

1548 Redwood Ct.

$8
Babysitting
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Merced, CA

Provide nutritious snacks and lunch, read to the

child, provide rest time for him/her, provide acticities
for him/her, supervise her/him at all times
Supervisors Name:
Sandy Vang
________________________________________________

_________________________________________________
_________________________________________________
_________________________________________________

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

Name

Complete Address (Include City, State, Zip)

Phone

Occupation_______

1.

________________________________________________________________________________________________________________________________
2.

________________________________________________________________________________________________________________________________
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:_________________________________________________________________