ROP APPLICATION

Directions: Please Print Legibly

Santana Abraham
Name: __________________________________________ 05-03-2017
____________________
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

3338 Campus Dr,
(P.O. Box or Street Number)

Merced California 95348

_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 201-2976 ( 209 )____________________

201-3835 santana7310@yahoo.com
____________________________
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

Merced Physical Therapy Internship

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

-Well Prepared, Hard-Working, Nice.

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 Y2882789
_______________________
(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 Merced High School Merced, Ca. N/A 1 2 3 4 Yes Yes

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

Yes Yes Yes

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:
Five Guys Burgers & Fries Salary: _____________
Title__________________________Last $120 Five Guys Burgers & Fries
_________________________________________________
6-3-16
______ 8-10-16
______
Mo / Yr Mo/Yr
Duties
3572 G ST, Merced, CA 95340
_________________________________________________
0 2
Total ____Yrs. ________Mo. In charge of cleaning, and pre cooking fries. (209) 205-4312
_________________________________________________
40-45
Hours Per Week:_________
Reason For Leaving: _________________________________________________

Supervisors Name: _________________________________________________

_____________________________________________________

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

_________________________________________________
Supervisors Name:
________________________________________________

From: To:
Title___________________________Last Salary: ____________ _________________________________________________
______ ______
Mo /Yr Mo/Yr Duties: _________________________________________________
Total ____Yrs. ________Mo. _________________________________________________
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.
Steve Eccles 205 W Olive Ave, Merced, CA 95348 209-325-1000
Teacher/Coach
________________________________________________________________________________________________________________________________

2. Betsy Bell 205 W Olive Ave, Merced, CA 95348 209-325-1000

School Nurse
________________________________________________________________________________________________________________________________

Christopher Grattan 205 W Olive Ave, Merced, CA 95348 209-325-1000

3.
Teacher Coach
________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

I understand that misrepresentation or omission of facts is cause for dismissal.

Date:_________________________Signature:_________________________________________________________________

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