ROP APPLICATION

Directions: Please Print Legibly

Xiong
Jerry
Name: __________________________________________

(Last)

(First)

04/21/15
____________________

(Middle)

Date

1412 Loughborough Dr.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95348
_______________________________________________________________________________

(City)

(State)

(209 ) 725-2946

(Zip Code)

Majayyer209@gmail.com
617-1546
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

(Telephone Number)

Position applied for:_______________________________________________________________

Any position avalible
Skills and/or competencies which qualify you for this position:
Active, handy with tools, good social communication and positive at all times

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

_______________________
(Number)

RECORD OF EDUCATION

Name of School
High School

City/State

Course of
study or
major

Last year
completed

Did you
graduate?

Diploma
or degree

Merced High Scool

Merced/CA

General
education

1 2 3 4

yes

diploma

College/
University

Merced college

Merced/CA

Auto
mechanic

1 2 3 4

pending

pending

Other
(Specify)

N/A

1 2 3 4

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

FULL TIME

AVAILABILITY
SUNDAY

PART TIME

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

Available

Available

Available

Availabe

Available

SATURDAY

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
Member
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Attend mettings and community activity

_________________________________________________

To:

2013
______

2015
______

Mo / Yr

Mo/Yr

11
1
Total ____Yrs.
________Mo.

205 west olive ave.

50
Hours Per Week:_________
Reason For Leaving:
graduating

From:

Leo Club

Merced, CA 95348
(209)385-6465

_________________________________________________
Supervisors Name:
Pos Moua
_____________________________________________________

_________________________________________________

Title__________________________Last Salary: _____________

_________________________________________________

Duties:

_________________________________________________

To:

______

______

Mo/ Yr

Mo/Yr

Total ____Yrs. ________Mo.

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

_________________________________________________
_________________________________________________
Supervisors Name:
________________________________________________

From:

To:

______

______

Mo /Yr

Mo/Yr

Title___________________________Last Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Total ____Yrs. ________Mo.

_________________________________________________

Hours Per Week:_________

Reason For Leaving:

_________________________________________________

Supervisors Name:
________________________________________________

_________________________________________________

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

Name
1.

Billy Thao

Complete Address (Include City, State, Zip)

2432 Beachwood Dr.

Phone

Occupation_______

(209)261-5397
Target Cashier

Merced, CA 95348

________________________________________________________________________________________________________________________________
2. Nhia

Thao

2432 Beachwood Dr.

(209)233-5160
Scholle team lead

Merced, CA 95348

________________________________________________________________________________________________________________________________
3.

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________