ROP APPLICATION

Directions: Please Print Legibly

Cook
Jermon
M
Name: __________________________________________

(Last)

(First)

04/30/15
____________________

(Middle)

Date

1367 Rincon Dr
Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

California
Merced
95348
_______________________________________________________________________________

(City)

(209 ) 489-8365
(Telephone Number)

(State)

(Zip Code)

jermoncook@gmail.com
602-9575
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Position applied for:_______________________________________________________________

School Psychologist Internship
Skills and/or competencies which qualify you for this position:
Excellent social skills, hard working, expert knowledge of Microsoft Office and the Internet

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

_______________________
F5455023
(Number)

RECORD OF EDUCATION

Name of School
High School

City/State

Merced High School

Merced,CA

Course of
study or
major

Last year
completed

Did you
graduate?

General Ed

1 2 3 4

In Progress

College/
University

Diploma
or degree

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Merced High Link Crew- Assisted incoming freshmen with the transition to high school from middle school.
3 years of Varsity Football, Varsity Basketball Starter
FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Anytime

3-11

3-11

3-11

3-11

3-11

Anytime

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

$150 per week

Courtesy Clerk
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

04/2015
______

Present
______

Mo / Yr

Mo/Yr

1
Total ____Yrs. ________Mo.
20-24
Hours Per Week:_________
Reason For Leaving:

From:

Raley's Supermarket

3350 North G Street, Merced, CA 95340

Asssisted customers in bagging groceries, maintain

sanitation of store by sweepinng, dusting, &
mopping

(209) 722-3689

_________________________________________________
_________________________________________________

Supervisors Name:
Frank Durazo
_____________________________________________________

_________________________________________________

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.

Steven DiSalvo

Complete Address (Include City, State, Zip)

205 West Olive Ave, Merced,CA 95341

Phone

Occupation_______

(209) 201-3784
Gov. Teacher

________________________________________________________________________________________________________________________________
2. Kurt

Smoot

205 West Olive Ave, Merced,CA 95341

School Counselor

________________________________________________________________________________________________________________________________
3. Rob

Scheidt

205 West Olive Ave, Merced,CA 95341

(209) 658-9517
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:_________________________________________________________________