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ROP APPLICATION
Directions: Please Print Legibly

Name: __________________________________________
Lee Larry ____________________
March 22, 2017
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

117 E San Pedro St.
(P.O. Box or Street Number)

Merced CA 95341
_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 261-6405 ( )____________________

n/a ____________________________
leelarry158@yahoo.com
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

dental aide

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

CPR/first aid, knowledge of vital signs, medical terminology, blood borne pathogens training, HIPAA
training, OSHA training, patient transfers, gait training, and medical office skills including scheduling,
translating, etc.

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:________________________________

Do you possess a valid California Drivers License?

No Yes
_______________________
F8069105
(Number)

RECORD OF EDUCATION
Course of
study or Last year Did you Diploma
Name of School City/State major completed graduate? or degree
High School 1 2 3 4 general
Golden Valley High School Merced, CA general Pending
June 2017
College/ 1 2 3 4
University n/a n/a n/a n/a n/a

Other
1 2 3 4
(Specify) n/a n/a n/a n/a n/a

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

Leo Clubs, ICC Clubs, 4-H Club, Courses: ROP Medical Technologies

FULL TIME
AVAILABILITY PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

10:00a-6:00p after 3:00p after 3:00p n/a after 3:00p after 3:00p 1:00p-7:00p
RECORD OF EMPLOYMENT: (Begin with your most recent job)

Period of Employment Job Title and Duties Performed Company Name, Address, and Phone Number
From: To:
dental aide
Title__________________________Last volunteer
Salary: _____________
Von Goodin, DDS Cosmetic and Family Dentistry
_________________________________________________
02/17
______ current
______
Mo / Yr Mo/Yr
Duties
830 West Olive Avenue
_________________________________________________
0
Total ____Yrs. 2
________Mo.
Perio chart, clean tray, refill stilled water. Merced, CA 95348
_________________________________________________
3
Hours Per Week:_________
Reason For Leaving: (209) 384-3434
_________________________________________________
n/a
Supervisors Name: _________________________________________________
Sheri William
_____________________________________________________

From: To:
volunteer Icon Dental Laboratory
dental laboratories assistant Salary: _____________
Title__________________________Last _________________________________________________
06/15
______ 02/16
______
Mo/ Yr Mo/Yr Duties:
235 W 12th St # H
_________________________________________________
8
Total ____Yrs. ________Mo. Merced, CA 95341
Responsible for cooking dentures, waxing dentures, _________________________________________________
20
Hours Per Week:_________ housekeeping, clean dentures. (209) 383-5875
Reason For Leaving: _________________________________________________

n/a _________________________________________________
Supervisors Name:
Alan Lee
________________________________________________

From: To:
kitchen
Title___________________________Last $10.50/hr
Salary: ____________
Sonic Drive-In
_________________________________________________
09/16
______ current
______
Mo /Yr Mo/Yr Duties:
1101 W 18th St
_________________________________________________
0
Total ____Yrs. 7
________Mo. Food preparation, wash trays, mop floor, house Merced, CA 95340
_________________________________________________
15
Hours Per Week:_________ keeping. Obtained FoodSafe certificate. (209) 383-3281
Reason For Leaving: _________________________________________________

school _________________________________________________
Supervisors Name:
David Thao
________________________________________________

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

Name Complete Address (Include City, State, Zip) Phone Occupation_______
1.
Jerry Fragasso 2121 E. Childs Ave.
(559) 917-8148
ROP Instructor
Merced, CA 95341
________________________________________________________________________________________________________________________________

2. Bee Vang 1101 W 18th St (209) 455-0615

Manager at Sonic
Merced, CA 95340
________________________________________________________________________________________________________________________________

3. 1101 W 18th St (209) 761-2432

Chao Vang
Co-worker at Sonic
Merced, CA 95340
________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________

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