ROP APPLICATION

Directions: Please Print Legibly

Elmore
Patrick
Charles
Name: __________________________________________

(Last)

(First)

04/28/2015
____________________

(Middle)

Date

3564 San Francisco Street

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

California
Merced
95348
_______________________________________________________________________________

(City)

(State)

( 20 ) 7694084

(Telephone Number)

(Zip Code)

patrickelmore87@gmail.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Social Worker
Skills and/or competencies which qualify you for this position:
Writer, works well in any environment, reliable, real life experiences, public speaking skills, typing skills,
and have a braod understanding for human interaction

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

_______________________
F5268544

(Number)

RECORD OF EDUCATION

Name of School
High School

College/
University

City/State

Course of
study or
major

Merced High School

Merced

HS
Diploma

CSU Fresno

Fresno

BA

Other
(Specify)

Last year
completed
1 2 3 4

Did you
graduate?

Diploma
or degree

Yes

HS
Diploma

1 2 3 4

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Donation, homeless shelters, hospital, adoption centers, kids in a home

FULL TIME

AVAILABILITY
SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

PART TIME

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

Title__________________________Last Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

______

______

Mo / Yr

Mo/Yr

Total ____Yrs. ________Mo.

_________________________________________________
Hours Per Week:_________
Reason For Leaving:

From:

_________________________________________________
Supervisors Name:
_____________________________________________________

_________________________________________________

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.

Sam Reyes

Complete Address (Include City, State, Zip)

4872 Durant Way Merced, CA 95348

Phone

Occupation_______

(209)628-3872

________________________________________________________________________________________________________________________________
2. Hunter

Fink

1989 El Portel Merced, CA 95348

(209)756-4258

________________________________________________________________________________________________________________________________
3.

Cassie Marler

118 w. 20th street Merced, CA 95340

(209)917-0852

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

4/28/2015
Date:_________________________Signature:_________________________________________________________________