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ROP APPLICATION
Directions: Please Print Legibly
Pena
Graciela
Patricia
Name: __________________________________________

(Last)

(First)

March 4, 2016
____________________

(Middle)

Date

1576 E Alexander ave

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
95340
Merced
_______________________________________________________________________________

(City)

(State)

( 209 ) 255-3456

(Zip Code)

gpena103290@muhsdstudents.org
369-5753
( 559 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

(Telephone Number)

Nursing Aide
Position applied for:_______________________________________________________________

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

Certified in First Aid, CPR, OSHA, and HIPAA
Articulate with great communication skills
Detail oriented and organized
Able to take vital signs

Languages spoken and/or written (other than English):___________________________________

N/A
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

City/State

Course of
study or
major

Merced High Shool

Merced, CA

Diploma

College/
University

Merced Collage

Merced, CA

nursing

Other
(Specify)

n/a

n/a

n/a

High School

Last year
completed
1 2 3 4

1 2 3 4

1 2 3 4

Did you
graduate?

Diploma
or degree

Pending
June 2016

General

n/a

n/a

n/a

n/a

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Club: Cosmetology club Link Crew Courses: AP English, Biology, Physics, Child Development

FULL TIME

AVAILABILITY
SUNDAY

10:00a-6:00p

MONDAY

After 3:00p

TUESDAY

After 3:00p

WEDNESDAY

N/A

PART TIME

THURSDAY

After 3:00p

FRIDAY

After 3:00p

SATURDAY

N/A

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
Pizza Maker
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Make pizzas, stock food, make sandwiches

_________________________________________________

To:

10/15
______

Present
______

Mo / Yr

Mo/Yr

0
5
Total ____Yrs.
________Mo.

1111 Loughborough Dr, Merced, CA 95348

15
Hours Per Week:_________
Reason For Leaving:
N/A

From:

5/15
______

Mo/ Yr

Mo/Yr

8
0
Total ____Yrs.
________Mo.

(209) 722-3661

_________________________________________________
Supervisors Name:
Erma
_____________________________________________________

_________________________________________________

$8/hr
Title__________________________Last
Salary: _____________
Saleswoman

_________________________________________________

Duties:

_________________________________________________

Sale shoes, great customers, handle money

_________________________________________________

To:

11/14
______

Pizza Villa

Flea Market

900 G street Merced, Ca

Hours Per Week:_________

12
Reason For Leaving:

(209) 354-4689

_________________________________________________
_________________________________________________

seasonal
Supervisors Name:
Luis Ramirez
________________________________________________
From:

To:

1/13
______

5/13
______

Mo /Yr

Mo/Yr

Total ____Yrs. ________Mo.

Hours Per Week:_________
Reason For Leaving:

school

Happy Face Day Care

$8/hr
Child Care Provider
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Cook, clean, supervise children, record their

behavior,and handled money

_________________________________________________

2752 Bronco Ave Merced, CA

(29) 628-0345

_________________________________________________

Supervisors Name:
Rosalinda Reyes
________________________________________________

_________________________________________________

REFERENCES: Give the names of three persons not related to you.

Name
1.

Gerald Fragasso

Complete Address (Include City, State, Zip)

Phone

Occupation_______

2121 E. Childs Ave.

Merced, CA 95341

(559) 917-8148

ROP Instructor

________________________________________________________________________________________________________________________________

895 La Jolla Way

2.

Thomas Briggs

(209) 349-2446

Teacher

Merced, CA 95348

________________________________________________________________________________________________________________________________

205 W. Olive Ave.

3.

Alex Muro

(209) 385-6454

Merced, CA 95344

Attendance Liaison

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________

N:\ROP\Charlotte Klock\ROP Forms\Forms\ROP Job Application with availbility back-for fillable.rtf

Revised 7/10