ROP APPLICATION

Directions: Please Print Legibly

Saelee
Meix
Sessica
Name: __________________________________________

(Last)

(First)

4/28/15
____________________

(Middle)

Date

1387 Jenner DR
Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95348
_______________________________________________________________________________

(City)

(State)

(209 ) 947-2726

(Telephone Number)

(Zip Code)

Saeleesessica@gmail.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Intern midwive
Skills and/or competencies which qualify you for this position:
Excellent people skills
Good communication and Observation
Can deal with different emotions and changed situations
N/A
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

Course of
study or
major

City/State

Merced High

Merced CA

College/
University

Last year
completed

Did you
graduate?

Diploma
or degree

1 2 3 4

Yes

Diploma

1 2 3 4

Other
(Specify)

1 2 3 4

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

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

1--9

1-9

1-9

1-9

1-9

1-9

1-9

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Sales Associate
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Attend to customers
Cashier

_________________________________________________

To:

2 2015
______

4 2015
______

Mo / Yr

Mo/Yr

Total ____Yrs. ________Mo.

Hours Per Week:_________
Reason For Leaving:

Currently still working there

From:

Pac Sun

Merced Mall barbershop

713 Merced Mall Merced ca 95348

209-385-9823

_________________________________________________
Supervisors Name:
Jasmin
_____________________________________________________

_________________________________________________

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.

Imelda Marquez

Complete Address (Include City, State, Zip)

1387 Jenner DR Merced Ca

Phone

Occupation_______

209-631-3544
N/A

________________________________________________________________________________________________________________________________
2. Toula

Mua

209-201-2634
Merced County

________________________________________________________________________________________________________________________________
3. Kourtner

209-761-9282
Social Worker

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________