ROP APPLICATION

Directions: Please Print Legibly

Deere
Taylor
Alyssa
Name: __________________________________________

(Last)

(First)

4/20/2015
____________________

(Middle)

Date

3368 San Mateo ct

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

California
Merced
95348
_______________________________________________________________________________

(City)

(209 ) 4899030

(State)

(Telephone Number)

(Zip Code)

tdeere102842@muhsdstudents.org
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Lab Assistant
Skills and/or competencies which qualify you for this position:
I have conducted many experiments throughout high school, and used the proper steps to handle lab
equipment. I follow procedures in atimely manner, and execute the skills necassary to complete task in a
timely manner.
Spanish
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

General Ed.

1 2 3 4

Yes

Diploma

College/
University

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
FBLA (Future Business Leaders of America)- Position: Public Relations Officer

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

No

Yes

Yes

Yes

Yes

Yes

No

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Title__________________________Last Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

______

______

Mo / Yr

Mo/Yr

Total ____Yrs. ________Mo.

_________________________________________________
Hours Per Week:_________
Reason For Leaving:

From:

_________________________________________________
Supervisors Name:
_____________________________________________________

_________________________________________________

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.

John Kane

Complete Address (Include City, State, Zip)

Phone

Occupation_______

205 W. Olive Ave., Merced, C.A 95348

Teacher

________________________________________________________________________________________________________________________________
2. James

Holland

205 W. Olive Ave., Merced, C.A 95348

Teacher

________________________________________________________________________________________________________________________________
3. Gary

Graham

205 W. Olive Ave., Merced C.A 95348

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:_________________________________________________________________