ROP APPLICATION

Directions: Please Print Legibly

May 14, 2015
____________________

Judith
Name: Villanueva
__________________________________________

(Last)

(First)

(Middle)

Date

2977 Birmingham Ct.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA.
Merced
95340
_______________________________________________________________________________

(City)

(State)

(Zip Code)

676-8191 ____________________________
judy.xcvii@gmail.com
( 209)947-2372 ( 209 )____________________

(Telephone Number)

(Alternative Telephone Number)

(Email Address)

Radiology Aide
Position applied for:_______________________________________________________________

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

BLS Training, Vital Signs knowledge, CPR Medical Terminology, Bloodborne pathogens training, HIPAA Training, OSHA
Training, gait belt training

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

Course of
study or
major

Merced High School Merced, CA General

Last year
completed

Did you
graduate?

Diploma
or degree

1 2 3 4

Pending
June 2015

General

1 2 3 4
Merced College

Merced, CA

Nursing

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:
Cabin Leader at Camp Green Meadows, ROP Medical Occupations, Anatomy and Physiology, Spanish Speakers 1, Spanish
Speakers 2, Biology, AP English 3, and Chemistry
FULL TIME

AVAILABILITY
SUNDAY

MONDAY

TUESDAY

WEDNESDAY

x PART TIME
THURSDAY

FRIDAY

SATURDAY

2:00P-7:00P 5:30P-9:00P 5:30P-9:00P 5:30P-9:00P 6:30P-9:30P n/a 12:00P-5:00P

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

Period of Employment
From:

Company Name, Address, and Phone Number

Radiology Aide
Volunteer
Title__________________________Last
Salary: _____________

_________________________________________________
Mercy Medical Center, 1st Floor

Duties

333 Mercy Ave.

_________________________________________________

To:

02/15 current
______
______
Mo / Yr

Job Title and Duties Performed

Mo/Yr

0 ________Mo.
1
Total ____Yrs.

4
Hours Per Week:_________
Reason For Leaving:

From:

To:

Getting rooms ready for patients, cleaning rooms, making _________________________________________________

Merced, CA 95340
sure room is stalked up, making phone calls, getting
patients and talking them back
(209)564-5400
_________________________________________________
Supervisors Name:
_____________________________________________________
Kathy Monson

_________________________________________________

nothing
Babysitter
Title__________________________Last
Salary: _____________

2977 Birmingham Ct.

_________________________________________________

Duties:

Merced, CA 95340
_________________________________________________

______
03/10 current
______
Mo/ Yr

Mo/Yr

0
05 ________Mo.
Total ____Yrs.
4
Hours Per Week:_________

Keeping an eye on kids, making sure they eat, play with

them, clean the house, and making sure they fall asleep.

(209)676-8191
_________________________________________________
_________________________________________________

Reason For Leaving:

_________________________________________________
Supervisors Name:
Victor and Maria Villanueva
________________________________________________
From:

To:

Teacher's Assistant Salary:

____________
nothing
Title___________________________Last

205 West Olive Avenue

_________________________________________________

Duties:

Merced, CA 95348
_________________________________________________

01/15 current
______
______
Mo /Yr

Mo/Yr

0 ________Mo.
02
Total ____Yrs.
5
Hours Per Week:_________
Reason For Leaving:

(209) 385-6465
Correct papers, pass papers back, roll film, mix chemicals, _________________________________________________
take pictures, make copies, and edit yearbook
_________________________________________________

Supervisors Name:
Kelsey Thomas
________________________________________________

_________________________________________________

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

Name

Complete Address (Include City, State, Zip)

Phone

Occupation_______

1.

Gerald Fragasso

2121 E Childs Ave

(559)917-8148 ROP Instructor

Merced, CA 95341
________________________________________________________________________________________________________________________________
2.

205 West Olive Ave.

(209)756-8901

Child Development
Teacher

Merced, CA 95348
Tammie Meyer
________________________________________________________________________________________________________________________________
3.

1237 Bel Air Dr.

(209)769-7280

Friend's Mother

Francisca Flores
________________________________________________________________________________________________________________________________
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