Reset Form

Print Form

ROP APPLICATION
Directions: Please Print Legibly
Isis
Vanessa
Name: Lopez
__________________________________________

(Last)

(First)

5/13/2014
____________________

(Middle)

Date

1761 Lopes Ave.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

California
Merced
95341
_______________________________________________________________________________

(City)

(209 ) 725-9040
(Telephone Number)

(State)

(Zip Code)

L0v3.o.o.o.L0v3@gmail.com
261-6034
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Surgeon Assistant
Position applied for:_______________________________________________________________

Skills and/or competencies which qualify you for this position:

Patience, Fast learner, and Efficient Worker.

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

City/State

Course of
study or
major

High School

Merced High School

Merced, CA

College/
University

Last year
completed

Did you
graduate?

Diploma
or degree

1 2 3 4

June 5,
2014

Diploma

GED
1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Secretary Assistant, Community Service feeding the homeless, Youth director

FULL TIME

AVAILABILITY
SUNDAY

All Day

MONDAY

TUESDAY

WEDNESDAY

PART TIME

THURSDAY

FRIDAY

3 p.m.- 10 p.m. 3 p.m.- 10 p.m. 3 p.m.- 10 p.m. 3 p.m.- 10 p.m. 3 p.m.- 10 p.m.

SATURDAY

N/A

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Field Worker
$314.00
Title__________________________Last
Salary: _____________

Salinas
Farm, Patterson CA, (559) 543-7345
_________________________________________________

Duties

_________________________________________________

Weeding in the tomato fields.

_________________________________________________

To:

6/2014
______

8/2014
______

Mo / Yr

Mo/Yr

2
Total 0
____Yrs. ________Mo.
40
Hours Per Week:_________
Reason For Leaving:

It was a summer job and I

didn't want it to interfere
with school.
From:

_________________________________________________
Supervisors Name:
Rodrigo Martinez
_____________________________________________________

_________________________________________________

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)

Phone

Occupation_______

7665 Court Dr., Chowchilla, CA, 95342

Patricia Shelby

(209) 876-7858

Math Teacher

________________________________________________________________________________________________________________________________

6963 26th St., Merced, CA, 95340

2.

(209) 896-4753

Beatrice Lewis

Child care

________________________________________________________________________________________________________________________________

985 M St., Merced, CA, 95341

3.

Joshua Madison

(209) 356-7984

Car Seller

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

05/13/2014
Date:_________________________Signature:_________________________________________________________________

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

Revised 7/10