Reset Form

Print Form

ROP APPLICATION
Directions: Please Print Legibly
Isaac
Name: Santana
__________________________________________

(Last)

(First)

May 7th, 2014

____________________

(Middle)

Date

3338 Campus Dr.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

California
Merced
95348
_______________________________________________________________________________

(City)

(209 ) 385-1408
(Telephone Number)

(State)

(Zip Code)

polo079@yahoo.com
201-9924
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Pharmacist Assistant
Position applied for:_______________________________________________________________

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

Hard Worker
Always On Time
Strive to be the Best

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

_______________________
F5624990
(Number)

RECORD OF EDUCATION

Name of School

City/State

Course of
study or
major

High School

Last year
completed

Did you
graduate?

Diploma
or degree

Yes

Yes

1 2 3 4

Merced High School

Merced

College/
University

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Swim Team
Water Polo Team
FULL TIME

AVAILABILITY
SUNDAY

MONDAY

TUESDAY

After 2:00 p.m. After 4:00 p.m. After 4:00 p.m.

WEDNESDAY

Not Available

PART TIME

THURSDAY

FRIDAY

After 4:00 p.m. After 4:00 p.m.

SATURDAY

All Day

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

Complete Address (Include City, State, Zip)

Phone

Occupation_______

1.

Darren Hise

(209) 769-3537

Criminal Investigator

________________________________________________________________________________________________________________________________
2.

Betsy Bell

(209) 769-5025

Nurse at MHS

________________________________________________________________________________________________________________________________
3.

Seth Gentry

(209) 658-5270

Teacher at ECHS

________________________________________________________________________________________________________________________________

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