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ROP APPLICATION
Directions: Please Print Legibly
Govea
Diego
Name: __________________________________________

(Last)

(First)

4/19/2016
____________________

(Middle)

Date

860 W 9th St
Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
95341
Merced
_______________________________________________________________________________

(City)

(State)

( 209 ) 384-5818
(Telephone Number)

(Zip Code)

diegogovea209@gmail.com
264-1398
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Courtesy Clerk
Position applied for:_______________________________________________________________

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

Ability to show up on time. Ability to work at a fast pace.

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

Name of School
High School

City/State

Merced

Course of
study or
major

Merced, CA

College/
University

General
Education

Last year
completed
1 2 3 4

Did you
graduate?

Diploma
or degree

Pending
2016

Pending
2016

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Open-Close

4pm-10pm

4pm-10pm

4pm-10pm

4pm-10pm

4pm-Close

Open-Close

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Title__________________________Last Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

______

______

Mo / Yr

Mo/Yr

Total ____Yrs. ________Mo.

N/A

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

From:

_________________________________________________
Supervisors Name:
_____________________________________________________

_________________________________________________

Title__________________________Last Salary: _____________

_________________________________________________

Duties:

_________________________________________________

To:

______

______

Mo/ Yr

Mo/Yr

Total ____Yrs. ________Mo.

N/A

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

_________________________________________________
_________________________________________________
Supervisors Name:
________________________________________________

From:

To:

______

______

Mo /Yr

Mo/Yr

Total ____Yrs. ________Mo.

Title___________________________Last Salary: ____________

_________________________________________________

Duties:

_________________________________________________

N/A

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

_________________________________________________

Supervisors Name:
________________________________________________

_________________________________________________

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

Name
1.

Hector Nava

Complete Address (Include City, State, Zip)

205 W Olive Ave

Phone

209-385-6465

Occupation_______

Teacher

Merced, CA

________________________________________________________________________________________________________________________________
2. Steve

DiSalvo

205 W Olive Ave

209-385-6465
Teacher

Merced, CA

________________________________________________________________________________________________________________________________
3.

Erin WIlliams

205 W Olive Ave

209-385-6465

Merced, CA

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:_________________________________________________________________

N:\ROP\Charlotte Klock\ROP Forms\Forms\ROP Job Application with availbility back-for fillable.rtf

Revised 7/10