ROP APPLICATION

Directions: Please Print Legibly

Her Nou Chi
Name: __________________________________________

(Last)

(First)

____________________
March 19, 2015

(Middle)

Date

1575 Brookdale Dr.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

Merced CA 95340
_______________________________________________________________________________

(City)

(State)

( 209 ) 761-0640

(Telephone Number)

(Zip Code)

nouchih15@gmail.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Nursing Aide
Position applied for:_______________________________________________________________

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

Training in BLS, HIPAA, OSHA, and blood borne pathogens. Knowledge of vital signs, medical terminologies, and word
processing software such as MS Word and Excel. Bilingualism- Hmong and entry level Spanish.

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?
X No

Yes

If yes, explain:________________________________

Do you possess a valid California Drivers License?

X No

Yes

_______________________
(Number)

RECORD OF EDUCATION

Name of School
High School

College/
University
Other
(Specify)

City/State

Merced High School

Course of
study or
major

Merced, CA

General

Last year
completed

1 2 3 4

Did you
graduate?

Diploma
or degree

Pending June
General
2015

1 2 3 4
Merced College

Merced, CA

Nutrition 10

N/A N/A

1 2 3 4
N/A N/A N/A N/A N/A

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Dare-2-Care, volunteer at Mercy Medical Hospital, Interact Club, Club APS, KIWIN'S (President), Link Crew (Vice President).
Courses: ROP Medical Occupations, Chemistry, AP Biology, AP Stats
FULL TIME

AVAILABILITY
SUNDAY

MONDAY

TUESDAY

9:00a-6:00p

after 3:00p

after 3:00p

WEDNESDAY
after 3:00p

X PART TIME
THURSDAY
after 3:00p

FRIDAY

SATURDAY

after 3:00p

9:00a-6:00p

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Nursing Aide
Volunteer
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

02/15
______

Current
______

Mo / Yr

Mo/Yr

1260 North D St.

00
2
Total ____Yrs.
________Mo.

4
Hours Per Week:_________
Reason For Leaving:
N/A

From:

Call in patients and assess vital signs, clean work areas

and waiting areas

Mo/ Yr

______
Current
Mo/Yr

01 ________Mo.
9
Total ____Yrs.
Hours Per Week:_________
6-8
Reason For Leaving:

Merced, CA 95340
_________________________________________________
(209) 564-4500
_________________________________________________

Supervisors Name:
Irene Henson, RN
_____________________________________________________

_________________________________________________

Babysitter
Title__________________________Last
Salary: _____________
Volunteer

Her Residents
_________________________________________________

Duties:

1575 Brookdale Dr.

_________________________________________________

To:

06/13
______

Kids' Care

Responsible for the well-being of a 9 years old including

cooking meals and helping with homework

Merced, CA 95340
_________________________________________________
(209) 631-4918
_________________________________________________
_________________________________________________

N/A

Supervisors Name:
Ahley Her
________________________________________________

From:

To:

08/13
______

______
09/14

Mo /Yr

Mo/Yr

1
01 ________Mo.
0
Total ____Yrs.
5
Hours Per Week:_________
Reason For Leaving:

$9/hr
Cashier
Title___________________________Last
Salary: ____________

Merced High School Cafeteria

_________________________________________________

Duties:

205 W. Olive Ave.

_________________________________________________

Merced, CA 95341
Collect all money and information involving lunches/snacks_________________________________________________
sold and input all information into school database.
(209) 385-6465
_________________________________________________

Leadership class involved

my work hours during
Supervisors Name:
lunch
________________________________________________
Toni Herrera

_________________________________________________

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

Name

Complete Address (Include City, State, Zip)

Phone

Occupation_______

1.

2121 E. Childs Ave

Gerald Fragasso

(559) 917-8148

ROP Instructor

Merced, CA 95341
________________________________________________________________________________________________________________________________
2.

Janice Rogge

623 W. 13th St.

(209) 562-6284

Program Specialist

Merced, CA 95341
________________________________________________________________________________________________________________________________
3.

John Carlos

2771 Glen Ave.

(209) 756-4017

Kiwanis Advisor

Merced, CA 95340
________________________________________________________________________________________________________________________________

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