ROP APPLICATION

Directions: Please Print Legibly

Name: __________________________________________
Serrano Daphne ____________________
5/10/19
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

499 Elm Ave
(P.O. Box or Street Number)

Merced CA 95301
_______________________________________________________________________________
(City) (State) (Zip Code)

(209 ) 421-2274 ( )____________________ ____________________________

daphneserrano434@gmail.com
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

CNA

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

knows OSHA rules and regulations, Vital signs, CPR certified, knows patient care.

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 Driver’s License?

‰ No ‰ Yes _______________________
(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 1 2 3 4

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

8a.m-5p.m 8a.m-5p.m 8a.m-5p.m 8a.m-5pm 8a.m-5p.m

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: _________________________________________________

Supervisor’s Name: _________________________________________________

_____________________________________________________

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

_________________________________________________
Supervisor’s Name:
________________________________________________

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

_________________________________________________
Supervisor’s Name:
________________________________________________

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

Name Complete Address (Include City, State, Zip) Phone Occupation_______
1.
Jeff Hammer 123 E. 18 th Street, Merced, CA 95340 209/325-1700

________________________________________________________________________________________________________________________________

2. Jeff Dickey 205 W Olive Ave, Merced, CA 95348

________________________________________________________________________________________________________________________________

3. Zachary Abell 123 E. 18 th Street, Merced, CA 95340 209/325-1700

________________________________________________________________________________________________________________________________

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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