ROP APPLICATION

Directions: Please Print Legibly

Renteria
Mhari
Name: __________________________________________

(Last)

(First)

May 1, 2015
____________________

(Middle)

Date

1584 Santa Inez Ct.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95340
_______________________________________________________________________________

(City)

(209 ) 384-2484
(Telephone Number)

(State)

(Zip Code)

mrenteria101977@muhsdstudents.org
761-2080
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Position applied for:_______________________________________________________________

Entry Level Position in a Natural Medicine Practice
Skills and/or competencies which qualify you for this position:

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

_______________________
F4777603
(Number)

RECORD OF EDUCATION

Name of School
High School

City/State

Merced High School

Course of
study or
major

Last year
completed

Did you
graduate?

Diploma
or degree

Gen. Ed.

1 2 3 4

Yes

Diploma

Merced

College/
University

1 2 3 4

Other
(Specify)

1 2 3 4

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

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

ALL

ALL

ALL

ALL

ALL

ALL

ALL

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.

Gabe Romo

Complete Address (Include City, State, Zip)

San Juan Ct. Merced CA

Phone

Occupation_______

209-201-7666
Retail Manager

________________________________________________________________________________________________________________________________
2. Carina

Arroyo Morales

Estrella Ct. Merced CA

209-233-1041
Veterinary Technician

________________________________________________________________________________________________________________________________
3. Miranda

Geyser

Robin Ct. Merced CA

209-726-1157
Registered Nurse

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________