ROP APPLICATION

Directions: Please Print Legibly

Name: __________________________________________
XIONG HUE PAO ____________________
April 25, 2017
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

549 CONE AVENUE
(P.O. Box or Street Number)

MERCED CA 95341
_______________________________________________________________________________
(City) (State) (Zip Code)

(209 ) 230-8801 ( 209 )____________________

725-8326 ____________________________
paohuexiong53@gmail.com
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

PHYSICAL THERAPIST INTERN

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

Analytical skills and social skills that I have makes me fit for this position. I will pick up at anything that is
given to me. I will also communicate with and ask questions if I don't understand anything. WIth these skills,
I am able to communicate and understand patients as well as doctors.

HMONG
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
_______________________
Y3512176
(Number)

RECORD OF EDUCATION
Course of
study or Last year Did you Diploma
Name of School City/State major completed graduate? or degree
High School 1 2 3 4 Diploma
Merced High School Merced , General Pending
California Education 2017
College/ 1 2 3 4
University

Other
1 2 3 4
(Specify)

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

FULL TIME
AVAILABILITY PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

ALL DAY 4pm-9pm 4pm-9pm 4pm-9pm 4pm-9pm 4pm-9pm ALL DAY

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

Period of Employment Job Title and Duties Performed Company Name, Address, and Phone Number
From: To:
Title__________________________Last Salary: _____________ _________________________________________________
______ ______
Mo / Yr Mo/Yr
Duties _________________________________________________
Total ____Yrs. ________Mo.
_________________________________________________
Hours Per Week:_________
Reason For Leaving: _________________________________________________

Supervisors Name: _________________________________________________

_____________________________________________________

From: To:
N/A N/A
N/A
Title__________________________Last Salary: _____________ _________________________________________________
N/A
______ N/A
______
Mo/ Yr Mo/Yr Duties: _________________________________________________
N/A
Total ____Yrs. N/A
________Mo. _________________________________________________
N/A
Hours Per Week:_________
Reason For Leaving: _________________________________________________

_________________________________________________
Supervisors Name:
________________________________________________

From: To:
N/A
Title___________________________Last N/A
Salary: ____________
N/A
_________________________________________________
N/A
______ N/A
______
Mo /Yr Mo/Yr Duties: _________________________________________________
N/A
Total ____Yrs. N/A
________Mo. _________________________________________________
N/A
Hours Per Week:_________
Reason For Leaving: _________________________________________________

_________________________________________________
Supervisors Name:
________________________________________________

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

Name Complete Address (Include City, State, Zip) Phone Occupation_______
1.
PATRICIA ZARCO 205 WEST OLIVE AVENUE MERCED CA 95348 (209) 325-1000
COUNSELOR
________________________________________________________________________________________________________________________________

2. MARK ABEJUELA 205 WEST OLIVE AVENUE MERCED CA 95348 (209) 325-1000
TEACHER
________________________________________________________________________________________________________________________________

3. TAMMY MEYER 205 WEST OLIVE AVENUE MERCED CA 95348 (209)

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:_________________________________________________________________