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ROP APPLICATION
Directions: Please Print Legibly

March 4, 2016
____________________

Vang
Kathy
Pahoua
Name: __________________________________________
(Last)

(First)

(Middle)

Date

1564 Loughborough Dr.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
95348
Merced
_______________________________________________________________________________
(City)

(State)

( 707) 300-9585

(Zip Code)

( 209)____________________
____________________________
katalee69@gmail.com
628-3506

(Telephone Number)

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Radiology (X-ray Tech)
Skills and/or competencies which qualify you for this position:
Vital Signs, CPR, First Aid, HIPAA, OSHA, Bloodborne Pathogen, taking a patient out of bed/patient
transfer, Computer Graphics Design, Photography, Art

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, CA

X-ray

College/
University

Merced College

Merced, CA

x-ray

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

gerneral

n/a

n/a

n/a

n/a

List appropriate extracurricular activities, clubs, organizations and courses for this position:
volunteer at Mercy Medical Center, Asian Club (Secretary). Courses : ROP Medical Technologies, Nurse TA,
Computer Graphics 2, English 4, American Government
FULL TIME

AVAILABILITY
SUNDAY

12:00a - 4:00p

MONDAY

4:00p - 8:00p

TUESDAY

4:00p - 8:00p

WEDNESDAY

4:00p - 8:00p

THURSDAY

4:00p - 8:00p

FRIDAY

4:00p - 8:00p

PART TIME

SATURDAY

4:30p - 8:30p

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
x-ray
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Vital sign, x-ray

_________________________________________________

To:

3/16
______

current
______

Mo / Yr

Mo/Yr

3
Total ____Yrs. ________Mo.

333 Mercy Ave.

Merced, CA 95340

10
Hours Per Week:_________
Reason For Leaving:
n/a

From:

(209)564-5400

_________________________________________________
Supervisors Name:
Kathy Moson, Radiology
_____________________________________________________

_________________________________________________

$8.00/hour
Title__________________________Last
Salary: _____________
TA for a 3rd grader

_________________________________________________

Duties:

_________________________________________________

Help with spellings, reading, and math

_________________________________________________

To:

10/13
______

12/13
______

Mo/ Yr

Mo/Yr

3
0
Total ____Yrs.
________Mo.

Mercey Medical Center, 1st floor

Andrea Ostos

1560 Sacramento Dr.

Merced, CA 95348
(209)761-2657

Hours Per Week:_________

4
Reason For Leaving:

_________________________________________________
_________________________________________________

Not needed anymore

Supervisors Name:
Andrea Ostos
________________________________________________
From:

To:

10/2008
______

current
______

Mo /Yr

Mo/Yr

7
4
Total ____Yrs.
________Mo.

24/7
Hours Per Week:_________
Reason For Leaving:

n/a

Calyina Vang

$0.00
babysitter
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Responsible for 5 kids, health and safety's,

cleaning, cooking, changing 8 months dippers, help
8-5 year old with homeworks

_________________________________________________

1564 Loughborough Dr.

Supervisors Name:
Calyina Vang
________________________________________________

Merced, CA 95348
(209) 628-3506

_________________________________________________
_________________________________________________

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

(599) 917-8148

Occupation_______

ROP Instrusctor

Merced, CA 95341

________________________________________________________________________________________________________________________________
2. Andrea

DeLeon

205 W Olive Ave

(209) 777-2496
ELD/English Instructor

Merced, CA 95348

________________________________________________________________________________________________________________________________
3.

Betsy Bell

205 W Olive Ave

(209) 769-5025

Merced, CA 95348

Health Aide

________________________________________________________________________________________________________________________________

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