ROP APPLICATION

Directions: Please Print Legibly

Curry
Melissa
M
Name: __________________________________________

(Last)

(First)

4/22/15
____________________

(Middle)

Date

3161 Vickie Ct.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95340
_______________________________________________________________________________

(City)

(209 ) 233-9151
(Telephone Number)

(State)

(Zip Code)

melissacurry@me.com
237-1177
( 707 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Position applied for:_______________________________________________________________

Nurse Internship/ Outpatient Observation
Skills and/or competencies which qualify you for this position:
Pre- requisites in Nursing (under BSN major), Communication Skills, Listening Skills, Leadership Skills,
Hospital Volunteer Excerience, Clinical Experience

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

_______________________
F5515643
(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
In
progress

Merced High School

Merced, CA

General Ed

1 2 3 4

In progress

Point Loma Nazarene

University

San Diego, CA

Nuring
(BSN)

1 2 3 4

Accepted

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Mercy Medical Hospital Volunteer, Assosiation of Pre- Medical Students, Leadership, Ag Leadership, Relay for
Life, Babysitting/ Nannying, Raising a pig
FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

4:30pm-8pm

2:30pm-8pm

2:30pm-8pm

2:30pm-8pm

2:30pm-8pm

2:30pm-8pm

8am-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

$10/ hr
Nanny
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Feeding children, tutoring children, watching

children, bathing children, transporting children, etc.

_________________________________________________

To:

6/13
______

4/15
______

Mo / Yr

Mo/Yr

10
1
Total ____Yrs.
________Mo.
20hrs
Hours Per Week:_________
Reason For Leaving:
N/A

From:

2472 Dunn Rd.

4/15
______

Mo/ Yr

Mo/Yr

4
1
Total ____Yrs.
________Mo.
Hours Per Week:_________
20hrs
Reason For Leaving:

Merced, CA 95340
(209)564-7743

_________________________________________________
Supervisors Name:
Catherine Nutcher
_____________________________________________________

_________________________________________________

$12/ hr
Title__________________________Last
Salary: _____________
Nanny

_________________________________________________

Duties:

_________________________________________________

Feeding children, tutoring children, watching

children, bathing children, transporting children, etc.

_________________________________________________

To:

12/13
______

The Nutchers

The Gallos

2662 Atlantic St.

Merced, CA 95340
(209)628-5888

_________________________________________________

N/A

_________________________________________________
Supervisors Name:
Lori Gallo
________________________________________________

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.

Scott Vance

Complete Address (Include City, State, Zip)

Central Presbyterian Church

Phone

Occupation_______

(209)617-5578
Pastor

1929 Canal St. Merced CA 95340

________________________________________________________________________________________________________________________________
2. Bill

Frietas

Merced High School

(209)385-6465
Teacher

205 W Olive Ave. Merced CA 95348

________________________________________________________________________________________________________________________________
3. Jeff

Gresham

2606 Greenland Dr.

(209)658-1020

Merced, CA 95340

Morgage Lender

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________