ROP APPLICATION

Directions: Please Print Legibly

Vera Adriana
Name: __________________________________________

(Last)

(First)

03-22-2016
____________________

(Middle)

Date

3524 Oakhurst Ave

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95340
_______________________________________________________________________________

(City)

(State)

( 805 ) 402-9501

(Telephone Number)

(Zip Code)

adriana.vera98@yahoo.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Registered Nurse
Position applied for:_______________________________________________________________

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

problem solving, communication skills, compassion, critical-thinking, attention to detail and calm under
pressure

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

_______________________
(Number)

RECORD OF EDUCATION

High School

Name of School

City/State

merced high school

Merced, CA

Course of
study or
major

Last year
completed
1 2 3 4

College/
University

Did you
graduate?

Diploma
or degree

yes

diploma

1 2 3 4

Other
(Specify)

1 2 3 4

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

FULL TIME

AVAILABILITY
SUNDAY

open

MONDAY

12am-8pm

TUESDAY

12am-8pm

WEDNESDAY

12am-4pm

THURSDAY

1pm-8pm

FRIDAY

1pm-4pm

PART TIME

SATURDAY

open

RECORD OF EMPLOYMENT: (Begin with your most recent job)

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

9.00
wearhouse stocker
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

clean up, store things where they belong and

package

_________________________________________________

To:

10-15
______

1-16
______

Mo / Yr

Mo/Yr

0
3
Total ____Yrs.
________Mo.
2
Hours Per Week:_________
Reason For Leaving:
moved cities.

From:

Pacific Southwest Container

4530 Leckron Rd. (209)526-0444

Modesto, CA

_________________________________________________
Supervisors Name:
Donna
_____________________________________________________

_________________________________________________

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.

Almadina Benavides

Complete Address (Include City, State, Zip)

3524 Oakhurst Ave

Phone

(209)271-0782

Occupation_______

Medical Assistant

Merced, CA 95340

________________________________________________________________________________________________________________________________
2. Fabian

Villa

205 W Olive Ave

(209)385-6466
Teacher

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:_________________________________________________________________

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

Revised 7/10