ROP APPLICATION

Directions: Please Print Legibly

Lema
Rikki
Dynae
Name: __________________________________________

(Last)

(First)

4-28-15
____________________

(Middle)

Date

830 Groveland Ct.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95340
_______________________________________________________________________________

(City)

(State)

(209 ) 7615371
(Telephone Number)

(Zip Code)

rikkilema@yahoo.com
201-6562
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Position applied for:_______________________________________________________________

Nursing Internship
Skills and/or competencies which qualify you for this position:
I possess a desireable amount of qualities, like; organization, ambicious, smart, helpful, creative, and
outging.

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

_______________________
xxxxxxxxx
(Number)

RECORD OF EDUCATION

Name of School
High School

College/
University

City/State

Course of
study or
major

Last year
completed

Did you
graduate?

Diploma
or degree

yes

diploma

Merced High School

Merced

Nursing

1 2 3 4

Santa Barbara Community

college

Santa Barbara

Nursing

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Link Crew, Volunteering at Merced Hospital, Commissioner of Rallies (Link Crew), Feeding the Homeless, and
assistive care (hospice).
FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

0
Volunteering at Hospital
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Worked in the Kitchen, worked the front desk, and

discharging patients.

_________________________________________________

To:

10/13
______

10/14
______

Mo / Yr

Mo/Yr

12
1
Total ____Yrs.
________Mo.
4
Hours Per Week:_________
Reason For Leaving:

From:

Mercy Medical Center, Merced CA 95348

_________________________________________________
Supervisors Name:
Jan Sorges
_____________________________________________________

_________________________________________________

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.

Marcia- Marie Rosson

Complete Address (Include City, State, Zip)

Merced CA, 95340

Phone

Occupation_______

(209) xxx-xxxx
PE teacher

________________________________________________________________________________________________________________________________
2. Kassie

Mua

Merced CA, 95340

(209) xxx-xxxx
English Teacher

________________________________________________________________________________________________________________________________
3. Wendy

Ekizian

Merced CA, 95340

(209) xxx-xxxx
Chiropractor assist.

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________