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ROP APPLICATION
Directions: Please Print Legibly
Arteaga
Mario
Dillon
Name: __________________________________________

(Last)

(First)

04-18-2016
____________________

(Middle)

Date

3561 Cordova Ave.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA.
95340
Merced
_______________________________________________________________________________

(City)

( 209 ) 489-0732
(Telephone Number)

(State)

(Zip Code)

marteaga102893@muhsdstudents.org
777-4587
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Registered Nurse
Position applied for:_______________________________________________________________

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

Volunteers at the Hospital
Social Skills

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

College/
University

Name of School

City/State

Course of
study or
major

Merced High

CA

n/a

Merced

CA

n/a

Last year
completed
1 2 3 4

1 2 3 4

Other
(Specify)

Did you
graduate?

Diploma
or degree

no

no

no

no

1 2 3 4

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

AVAILABILITY
SUNDAY

Yes

MONDAY

Yes

TUESDAY

Yes

WEDNESDAY

Yes

FULL TIME
PART TIME

THURSDAY

Yes

FRIDAY

Yes

SATURDAY

Yes

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

n/a
Volunteer at Mercy Hopsital Salary: _____________
Title__________________________Last

_________________________________________________

Duties

_________________________________________________

Work at Lobby desk

Help Nurses on floors
Distribute Equipment to other Nurse stations

_________________________________________________

Supervisors Name:
_____________________________________________________

_________________________________________________

Title__________________________Last Salary: _____________

_________________________________________________

Duties:

_________________________________________________

To:

Aug 20
______

Continuing
______

Mo / Yr

Mo/Yr

n/a
Total ____Yrs. ________Mo.

4
Hours Per Week:_________
Reason For Leaving:

From:

Mercy Hospital,333 Mercy Ave, Merced, CA 95340,(20

_________________________________________________

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.

Mr. Camara

Complete Address (Include City, State, Zip)

Phone

205 W Olive Ave, Merced, CA 95348

(209) 385-6465

Occupation_______

Teacher

________________________________________________________________________________________________________________________________
2.

Mr. Freitas

205 W Olive Ave, Merced, CA 95348

(209) 385-6465
Teacher

________________________________________________________________________________________________________________________________
3.

Mrs. Rhonda Hernandez

333 Mercy Ave, Merced, CA 95340

(209) 564-5000

RN

________________________________________________________________________________________________________________________________

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