ROP APPLICATION

Directions: Please Print Legibly

Martinez-Gutierrez Antonia
Name: __________________________________________

(Last)

(First)

March 4, 2016
____________________

(Middle)

Date

3105 Meadows Ave Apt 22

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95348
_______________________________________________________________________________

(City)

(State)

( 209 ) 408-4257

(Telephone Number)

(Zip Code)

amartinez105526@gmail.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Nursing Aide
Position applied for:_______________________________________________________________

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

CPR Certified , Vital signs certified, First Aid Certified, HIPAA and OSHA Certified, Medical terminology
,Bloodborne pathogen certified , Patient transfer training , computer skills, communication skills, Bed baths
and changing patients with other nurse

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

Spanish
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
Course of
study or
major

Name of School

City/State

Merced HighSchool

Merced/CA

General
Education

College/
University

N/A

N/A

N/A

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
N/A

N/A

N/A

N/A

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Dare to Care , Medical Technologies , Anatomy and physiology

FULL TIME

AVAILABILITY
SUNDAY

5pm-7pm

MONDAY

5pm-7pm

TUESDAY

5-pm-7pm

WEDNESDAY

5pm-7pm

THURSDAY

5pm-7pm

FRIDAY

5pm-7pm

PART TIME

SATURDAY

6am-9pm

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Volunteer
Nursing Aide
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Taking vital signs, patient transfers, filinng papers

_________________________________________________

To:

02/2016
______

05/2016
______

Mo / Yr

Mo/Yr

4
Total ____Yrs. ________Mo.

333 Mercy Ave

6
Hours Per Week:_________
Reason For Leaving:

From:

02/2016
______

Mo/ Yr

Mo/Yr

Total ____Yrs. ________Mo.

Hours Per Week:_________
12
Reason For Leaving:

(209) 564-5000
Merced , CA

_________________________________________________
Supervisors Name:
Kelsey Rodriguez , RN
_____________________________________________________

_________________________________________________

Volunteer
Title__________________________Last
Salary: _____________
Child Care Provider

_________________________________________________

Duties:

_________________________________________________

Preparing meals, General House care, Giving baths

to the baby , Putting the baby to sleep

_________________________________________________

To:

08/15
______

Mercy Hospital , 5th floor

Martinez Family

3105 Meadows Ave Apt 22

(209) 355-8187
Merced , CA

_________________________________________________
_________________________________________________

It was only for nights

Supervisors Name:
Lupita Campos
________________________________________________
From:

To:

02/16
______

current
______

Mo /Yr

Mo/Yr

2
Total ____Yrs. ________Mo.
16
Hours Per Week:_________
Reason For Leaving:
current

AppleGate Zoo

Volunteer
Volunteer
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Cleaning animal exhibits, check the exhibit to see if

anything needs repairs, prepare animals diet, Host
a petting zoo.

_________________________________________________

1045 W. 25th Street

Supervisors Name:
Josh Merino
________________________________________________

(209) 385-6840
Merced , CA

_________________________________________________
_________________________________________________

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

Name
1.

Jerry Fragasso

Complete Address (Include City, State, Zip)

2121 E Childs Ave, Merced, CA 95341

Phone

(559) 917-8148

Occupation_______

Rop Instructor

________________________________________________________________________________________________________________________________
2. Linda

Clinton

205 W Olive Ave, Merced, CA 95348

(209) 232-9726
Vet Science Instructor

________________________________________________________________________________________________________________________________
3.

Maureen Johnson

205 W Olive Ave, Merced, CA 95348

(209) 385-6465
TA Instructor

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________