ROP APPLICATION

Directions: Please Print Legibly

Mognis
Courtney
Ann
Name: __________________________________________

(Last)

(First)

April 17, 3016

____________________

(Middle)

Date

Present mailing address:___________________________________________________________

2350 Westwood Drive
(P.O. Box or Street Number)
Californa
Merced
95340
_______________________________________________________________________________

(City)

(State)

( 209 ) 631-2785

(Zip Code)

courtcalifornia@gmail.com
( 209 )____________________
____________________________
274-8723
(Alternative Telephone Number)
(Email Address)

(Telephone Number)

Teacher's Assistant in Elementary Classroom

Position applied for:_______________________________________________________________

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

I have many sources of experience in the area of child care as well as assistance in the learning process.

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 School

Merced, CA

Last year
completed

Did you
graduate?

Diploma
or degree

1 2 3 4

Yes

Diploma

High
School
study

College/
University

N/A

1 2 3 4

Other
(Specify)

N/A

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Babysitter
After school care provider
Mentor
Link Crew
Middle School Youth Leader

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

9-5

12-3

12-3

11-4

12-3

10-2

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 per hour

Cashier
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

Dec 14
______

Apr 15
______

Mo / Yr

Mo/Yr

5
0
Total ____Yrs.
________Mo.
23
Hours Per Week:_________
Reason For Leaving:
Downsizing

From:

G Street 2844 Merced CA 95340

Cleaned and restocked shelves and showcases

Took inventory
Operated cash register
Gift wrapping
Supervisors
Name:
Francis Peraino
_____________________________________________________

To:

Dec 15
______

Present
______

Mo/ Yr

Mo/Yr

5
0
Total ____Yrs.
________Mo.
Hours Per Week:_________
5
Reason For Leaving:

Peraino's Jewelers and Gift Emporium

(209) 723-0763

_________________________________________________
_________________________________________________
_________________________________________________

St. Paul's Lutheran School

$10 per hour

Title__________________________Last
After School care provider Salary: _____________

_________________________________________________

Duties:

_________________________________________________

2916 Mckee Rd Merced CA 95340

Assisting in homework
Caring for children who stay after school
Providing first aid when necessary

N/A

(209) 383-3301

_________________________________________________
_________________________________________________
_________________________________________________

Supervisors Name:
Amy Mello
________________________________________________
From:

To:

______

______

Mo /Yr

Mo/Yr

Title___________________________Last Salary: ____________

_________________________________________________

Duties:

_________________________________________________

0
0
Total ____Yrs.
________Mo.

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

_________________________________________________

Supervisors Name:
________________________________________________

_________________________________________________

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

Name
1.

Amy Mello

Complete Address (Include City, State, Zip)

2916 Mckee Rd Merced CA 95340

Phone

Occupation_______

(209) 383-3301
Employer

________________________________________________________________________________________________________________________________
2. Joel

Scaap

353 E Donna Drive Merced, CA 95340

Youth Pastor

________________________________________________________________________________________________________________________________
3.

Dawn Brown

N/A

N/A
Previous Employer

________________________________________________________________________________________________________________________________

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