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ROP APPLICATION
Directions: Please Print Legibly

Name: __________________________________________
Moua
Xue
N/A
(Last)

(First)

____________________
02/04/15

(Middle)

Date

Present mailing address:___________________________________________________________

597 E San Xavier Ct
(P.O. Box or Street Number)

_______________________________________________________________________________
California
Merced
95341
(City)

( 209 ) 813-8161

(State)

(Telephone Number)

(Zip Code)

)____________________
____________________________
N/A
xuemoua12@outlook.com

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Salad bar/ Prep Cook
Skills and/or competencies which qualify you for this position:

bilingual
understanding and able to communicate effectively with others

Languages spoken and/or written (other than English):___________________________________

Hmong
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
High School

City/State

Merced High School

Course of
study or
major

Merced, CA

College/
University

GED

Last year
completed
1 2 3 4

Did you
graduate?

Diploma
or degree

pending
2015

pending
2015

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:

LEO CLUB
FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

2pm-8pm

4pm-9pm

4pm-9pm

4pm-9pm

4pm-9pm

4pm-9pm

2pm-8pm

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: _____________
Sizzlers

Sizzlers 1334 West Olive Avenue,

_________________________________________________

Duties

_________________________________________________

cook prep/ salad bar

_________________________________________________

To:

______
01/1

______
present

Mo / Yr

Mo/Yr

5/15

Total ____Yrs. ________Mo.

3

(209)723-710

Hours Per Week:_________

Reason For Leaving:

From:

_________________________________________________
Supervisors Name:
_____________________________________________________
Kae Saelee/ Mike Matsuo

_________________________________________________

Title__________________________Last
Salary: _____________
N/A

_________________________________________________

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: ____________
N/A

_________________________________________________

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.

Lisa Escobedo

Complete Address (Include City, State, Zip)

205 West Olive Avenue, Merced, CA 95348

Phone

(209)617-4608

Occupation_______

Teacher

________________________________________________________________________________________________________________________________
2. Pos

Moua

205 West Olive Avenue, Merced, CA 95348

(209)631-3490

Teacher

________________________________________________________________________________________________________________________________
3.

Gary Eno

Merced, CA 95348

(209)658-2345

Lion's Club
Advisor

________________________________________________________________________________________________________________________________

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