ROP APPLICATION

Directions: Please Print Legibly

Xiong
Na
Lee
Name: __________________________________________

(Last)

(First)

May 6, 2014
____________________

(Middle)

Date

1358 West 3rd Street

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

Ca
Merced
95341
_______________________________________________________________________________

(City)

(State)

(209 ) 725-8326

(Telephone Number)

(Zip Code)

naleexiong17@hotmail.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Any Available
Skills and/or competencies which qualify you for this position:
I had expericed many leadership skills. I was the club president for my 4-H club for two years. Some
projects that I was involve in was woodworking, sewing, arts and craft, cooking, and tech x-cite. I can work
well as a team and I always have a positive attitude.
Hmong and 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

_______________________
F4481482
(Number)

RECORD OF EDUCATION

Name of School
High School

City/State

Merced High

Course of
study or
major

Last year
completed

Did you
graduate?

Diploma
or degree

N/A

1 2 3 4

Still
Attending

N/A

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:
4-H, Key Club, Link Crew, Leo Club, Asian Club, Claws Afterschool Program

FULL TIME

AVAILABILITY
SUNDAY

MONDAY

TUESDAY

4pm-9pm

4pm-9pm

WEDNESDAY

PART TIME

THURSDAY

FRIDAY

SATURDAY

4pm-9pm

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Title__________________________Last Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

______

______

Mo / Yr

Mo/Yr

Total ____Yrs. ________Mo.

_________________________________________________
Hours Per Week:_________
Reason For Leaving:

From:

_________________________________________________
Supervisors Name:
_____________________________________________________

_________________________________________________

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.

Complete Address (Include City, State, Zip)

Som Reyna

Phone

Occupation_______

725-0880
4-H Volunteer

________________________________________________________________________________________________________________________________
2. Mr.

205 W Olvie Ave. Merced, Ca 95348

Lee

385-6467
Physics teacher

________________________________________________________________________________________________________________________________
3. Darlene

McIntyre

2145 Wardrobe Avenue Merced, Ca 95341

385-7403
4-H Representative

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________