ROP APPLICATION

Directions: Please Print Legibly

Xiong
Mai
Choua
Name: __________________________________________

(Last)

(First)

April 28, 2015

____________________

(Middle)

Date

1212w 3rd st
Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95341
_______________________________________________________________________________

(City)

(678 ) 975-2061

(State)

(Telephone Number)

(Zip Code)

ashgnoix@hotmail.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

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

Hmong
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

_______________________
(Number)

RECORD OF EDUCATION

Name of School
High School

City/State

Merced High School

Course of
study or
major

Last year
completed

Did you
graduate?

Diploma
or degree

Health

1 2 3 4

Diploma in
Progress

Diploma

Merced, CA

College/
University

1 2 3 4

Other
(Specify)

1 2 3 4

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

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

8a.m-10p.m

4a.m-10p.m

4a.m-10p.m

4a.m-10p.m

4a.m-10p.m

4a.m-10p.m

8a.m-10p.m

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

NA
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

______

______

Mo / Yr

Mo/Yr

Total ____Yrs. ________Mo.

_________________________________________________
Hours Per Week:_________
Reason For Leaving:

From:

_________________________________________________
Supervisors Name:
_____________________________________________________

_________________________________________________

Title__________________________Last
Salary: _____________
NA

_________________________________________________

Duties:

_________________________________________________

To:

______

______

Mo/ Yr

Mo/Yr

Total ____Yrs. ________Mo.

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

_________________________________________________
_________________________________________________
Supervisors Name:
________________________________________________

From:

To:

______

______

Mo /Yr

Mo/Yr

NA
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.

Jim Holland

Complete Address (Include City, State, Zip)

205 West Olive Ave, Merced, CA 95344

Phone

Occupation_______

(209)385-6465
History Teacher

________________________________________________________________________________________________________________________________
2. Kassie

Mua

205 West Olive Ave, Merced, CA 95344

(209)385-6465
English Teacher

________________________________________________________________________________________________________________________________
3. Tammie

Meyer

205 West Olive Ave, Merced, CA 95344

(209)385-6465
Health Teacher

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________