ROP APPLICATION

Directions: Please Print Legibly

Moua
Bryan
Name: __________________________________________

(Last)

(First)

3-4-16
____________________

(Middle)

Date

1280 East Donna Drive

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95340
_______________________________________________________________________________

(City)

(State)

( 209 ) 349-1442

(Telephone Number)

(Zip Code)

mouabryan@ymail.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Radiology Aide
Position applied for:_______________________________________________________________

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

CPR/First Aid, Vital Signs, Medical Terminology, Blood Borne Pathogens, HIPAA, OSHA, Translating.

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

Hmong
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 School

Merced

General

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

General

N/A

N/A

N/A

N/A

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Chemistry, AP Chemistry, Biology, ROP Med Tech,

FULL TIME

AVAILABILITY
SUNDAY

10:00a-7:00p

MONDAY

TUESDAY

After 3:00 pm

After 3:00 pm

WEDNESDAY

After 3:00 pm

THURSDAY

FRIDAY

After 3:00 pm

After 3:00 pm

PART TIME

SATURDAY

10:00a-7:00p

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
Radiology Aide
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Taking care of patients

_________________________________________________

To:

2/16
______

Current
______

Mo / Yr

Mo/Yr

0
2
Total ____Yrs.
________Mo.

333 Mercy Ave. Merced, CA 95340

5
Hours Per Week:_________
Reason For Leaving:
N/A

From:

Current
______

Mo/ Yr

Mo/Yr

7
1
Total ____Yrs.
________Mo.
Hours Per Week:_________
3
Reason For Leaving:

209-564-5000

_________________________________________________
Supervisors Name:
Kathy Monson
_____________________________________________________

_________________________________________________

volunteer
Title__________________________Last
Salary: _____________
Babysitter

_________________________________________________

Duties:

_________________________________________________

Responsible for three other children, Tutoring two of

the in general reading, writing, and math.

_________________________________________________

To:

7/14
______

Mercy Medical Center

1280 East Donna Drive

Merced, CA 95340
209-349-1442

_________________________________________________
_________________________________________________

N/A
Supervisors Name:
Parents
________________________________________________
From:

To:

1/11
______

Current
______

Mo /Yr

Mo/Yr

5
1
Total ____Yrs.
________Mo.
1
Hours Per Week:_________
Reason For Leaving:
N/A

1280 East Donna Drive

volunteer
Landscaper
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Caring for equipment, and cutting the grass, refuel

lawn mower

_________________________________________________

Merced, CA 95340
209-349-1442

_________________________________________________

Supervisors Name:
Parents
________________________________________________

_________________________________________________

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 .

Phone

559-917-8148

Occupation_______

ROP Insructor

Merced, CA. 95341

________________________________________________________________________________________________________________________________
2. Karen

Sizemore

205 West Olive

209-489-1576
English Teacher

Merced, CA. 95341

________________________________________________________________________________________________________________________________
3.

BIll Freitas

3345 Bashy Ct

209-384-2082

Merced CA, 95340

Physics 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:_________________________________________________________________