ROP APPLICATION

Directions: Please Print Legibly

Villanueva
Danielle
Lea
Name: __________________________________________

(Last)

(First)

April 16, 2016

____________________

(Middle)

Date

3017 Aspen St.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95340
_______________________________________________________________________________

(City)

(209 ) 261-0403
(Telephone Number)

(State)

(Zip Code)

daniellevillanueva13@gmail.com
356-5408
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Position applied for:_______________________________________________________________

Chiropratic Receptionist
Skills and/or competencies which qualify you for this position:
Answers phone, Takes orders, schedule appointments, retrieve equipment, account for money in register,
file paper work, clean and organize the office

N/A
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

_______________________
(Number)

RECORD OF EDUCATION

Name of School
High School

College/
University

City/State

Course of
study or
major

Last year
completed

Did you
graduate?

Diploma
or degree

Merced High School

Merced

General
Education

1 2 3 4

2016

Diploma

Merced Junior College

Merced

Phychology

1 2 3 4

N/A

N/A

Other
(Specify)

1 2 3 4

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

FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Anytime

Evening

Evening

Evening

Evening

Evening

Anytime

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Minimum Wage
Waitress
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Wait orders, deliver food, answers phone, serve

beverages, clean tables, put dishes away

_________________________________________________

To:

9/15
______

Present
______

Mo / Yr

Mo/Yr

6
1
Total ____Yrs.
________Mo.
10
Hours Per Week:_________
Reason For Leaving:

From:

Taste of Little India, Main St., 209-722-2230John

_________________________________________________
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.

John Rivero

Complete Address (Include City, State, Zip)

W. Olive Ave. Merced, CA, 95340

Phone

Occupation_______

(209) 631-3557
Teacher

________________________________________________________________________________________________________________________________
2. Keefe

Kullen

Taste of Little India, Merced, CA, 95340

(209) 445-5092
Coworker

________________________________________________________________________________________________________________________________
3. Parm

Samira

Taste of Little India, Merced, CA, 95340

(209) 722-2230
Business Owner

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________