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ROP APPLICATION
Directions: Please Print Legibly
Lee
Michelle
Name: __________________________________________

(Last)

(First)

2/8/16
____________________

(Middle)

Date

2091 Lopes Avenue

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
95341
Merced
_______________________________________________________________________________

(City)

(State)

( 209 ) 756-6565

(Zip Code)

mlee103142@muhsdstudents.org
not applicable
( n/a )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

(Telephone Number)

Pharmacy Aide
Position applied for:_______________________________________________________________

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

CPR/first aid, vital signs, medical terminology, basic pharmacology, blood borne pathogens, HIPAA, OSHA,
knowledge in office programs such as MS Word, Excel, etc., phone etiquette, multitasking, scheduling,
communication skills

Languages spoken and/or written (other than English):___________________________________

Hmong
Have you ever been convicted, pleaded guilty or no contest to a misdemeanor or felony?
No

Yes

If yes, explain:________________________________
not applicable

Do you possess a valid California Drivers License?

No

Yes

_______________________
not applicable
(Number)

RECORD OF EDUCATION

Name of School

City/State

Course of
study or
major

Merced High School

Merced, CA

general

College/
University

not applicable

not applicable

not
applicable

Other
(Specify)

not applicable

not applicable

not
applicable

High School

Last year
completed
1 2 3 4

1 2 3 4

1 2 3 4

Did you
graduate?

Diploma
or degree

Pending
June 2016

general

not
applicable

not
applicable

not
applicable

not
applicable

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Courses: ROP Medical Technologies, Anatomy and Physiology, Chemistry, Computer Applications, Health and
Wellness, ERWC/English 4
FULL TIME

AVAILABILITY
SUNDAY

available

MONDAY

available

TUESDAY

available

WEDNESDAY

available

THURSDAY

available

FRIDAY

available

PART TIME

SATURDAY

available

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
Pharmacy Aide
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

isolating expired medication, filling out prescriptions,

and ensure that patients receive correct medication

_________________________________________________

To:

2/16
______

5/16
______

Mo / Yr

Mo/Yr

0
2
Total ____Yrs.
________Mo.

4.5
Hours Per Week:_________
Reason For Leaving:
not applicable

From:

3377 G Street, Ste. B

current
______

Mo/ Yr

Mo/Yr

60
5
Total ____Yrs.
________Mo.
Hours Per Week:_________
168
Reason For Leaving:

not applicable

Merced, CA 95341
(209) 384-8880

_________________________________________________
Supervisors Name:
Samantha Martinez
_____________________________________________________

_________________________________________________

various
Title__________________________Last
Salary: _____________
Babysitter

_________________________________________________

Duties:

_________________________________________________

responsible for the health and safety of 3 children,

ages 5, 2, and 1, and 1 autistic sibling, age 20.
Cooking meals, playing, helping 5 year old with
homework

_________________________________________________

To:

5/11
______

El Portal Pharmacy

Vaneng Xiong

2091 Lopes Avenue

Merced, CA 95341
(209) 500-7362

_________________________________________________
_________________________________________________

Supervisors Name:
Vaneng Xiong
________________________________________________
From:

To:

8/07
______

6/12
______

Mo /Yr

Mo/Yr

6
72
Total ____Yrs.
________Mo.

various
Hours Per Week:_________
Reason For Leaving:

not applicable

Alicia Reyes Elementary

volunteer
Teacher's Assistant
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

running errands, correcting papers, making copies,

cleaning classroom

_________________________________________________

123 S N St

Merced, CA 95341
(209) 385-6761

_________________________________________________

Supervisors Name:
Vaneng Xiong
________________________________________________

_________________________________________________

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

Name
1.

Gerald Fragasso

Complete Address (Include City, State, Zip)

2121 E. Childs Ave.

Phone

(559) 917-8148

Occupation_______

ROP Instructor

Merced, CA 95341

________________________________________________________________________________________________________________________________
2. Del

Camara

205 W. Olive Ave.

(209) 385-6465
Art Instructor

Merced, CA 95341

________________________________________________________________________________________________________________________________
3.

Samantha Martinez

3377 G Street Ste. B

(209) 384-8880

Merced, CA 95341

Job Site Supervisor

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________

N:\ROP\Charlotte Klock\ROP Forms\Forms\ROP Job Application with availbility back-for fillable.rtf

Revised 7/10