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ROP APPLICATION
Directions: Please Print Legibly
Rodriguez Jaquelin
Name: __________________________________________

(Last)

(First)

April 18,2016
____________________

(Middle)

Date

Present mailing address:___________________________________________________________

685 Santa Barbara Ct.
(P.O. Box or Street Number)
CA
Merced
95348
_______________________________________________________________________________

(City)

(State)

( 209 ) 3547337

(Telephone Number)

(Zip Code)

jrodriguez103339@gmail.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Registered Nurse
Position applied for:_______________________________________________________________

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

Communication skills, patience, patient care, uplifting personality, medical experience, and responsibility.

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

Course of
study or
major

City/State

Merced High School

Merced CA

College/
University

Last year
completed

Did you
graduate?

Diploma
or degree

1 2 3 4

yes

yes

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Mercy Medical Center volunteer.

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

all day

all day

all day

all day

all day

all day

all day

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Decorator/ Organizer
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Decorate parties, serve guests, and organize

events,

_________________________________________________

To:

06/14
______

06/15
______

Mo / Yr

Mo/Yr

Total ____Yrs. ________Mo.

6
Hours Per Week:_________
Reason For Leaving:

Piccolina's Party 602 W Main St., Merced Ca

(209)726 5292

_________________________________________________

Seasonal

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.

Vanesa C. Sandoval

Complete Address (Include City, State, Zip)

602 W Main St., Merced, CA 95348

Phone

Occupation_______

(209)7265292

Previous Employee
________________________________________________________________________________________________________________________________
2. Meyer

205 W Olive Ave., Merced, CA 95348

(209)
Teacher

________________________________________________________________________________________________________________________________
3.

Isac Chavez

N/A

(209)7234340
Co-Worker

________________________________________________________________________________________________________________________________

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