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ROP APPLICATION
Directions: Please Print Legibly

Name: __________________________________________
Carpenter Francess D. ____________________
March 22, 2017
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

1015 Century Circle
(P.O. Box or Street Number)

Merced CA 95340
_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 123-4567 ( 209 )____________________

765-4321 ____________________________
imastudent@gmail.com
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

nursing aide

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

CPR/first aid, knowledge of vital signs, medical terminology, basic pharmacology, blood borne pathogens
training, HIPAA training, OSHA training, patient transfers, gait training, MS Word, Excel, and medical office
skills including scheduling, phone etiquette, organization skills, etc.

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
_______________________
Y2940963
(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
Merced 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:

Volunteer at Mercy Medical Center, Link Crew, Varsity Swimming/ Water Polo, Miss Merced County. Courses:
ROP Medical Technologies, Chemistry, Health and Family Living, AP English, Anatomy and Physiology, Honors
Spanish, AP Physics.
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:
nursing aide
Title__________________________Last n/a
Salary: _____________
Mercy Medical Center, FBC
_________________________________________________
01/17
______ current
______
Mo / Yr Mo/Yr
Duties
333 Mercy Ave.
_________________________________________________
0
Total ____Yrs. 3
________Mo.
patient histories, patient transfers, patient Merced, CA 95340
_________________________________________________
5
Hours Per Week:_________ education, handing out waters.
Reason For Leaving: (209) 564-5400
_________________________________________________
n/a
Supervisors Name: _________________________________________________
Cece Sarmiento, RN
_____________________________________________________

From: To:
$25.00/day Louina Papilota
babysitter
Title__________________________Last Salary: _____________ _________________________________________________
06/15
______ current
______
Mo/ Yr Mo/Yr Duties:
1234 Main Street
_________________________________________________
1
Total ____Yrs. 9
________Mo. Merced, California, 95340
Responsible for the health and safety of 2 children, _________________________________________________
8
Hours Per Week:_________ ages 4 and 9. Also in charge of preparing at least (209) 658-6085
Reason For Leaving: lunch or snacks along with putting them to bed _________________________________________________

n/a
accordingly. _________________________________________________
Supervisors Name:
Parent's name
________________________________________________

From: To:
Title___________________________Last Salary: ____________ _________________________________________________
______ \
______
Mo /Yr Mo/Yr Duties: _________________________________________________
Total ____Yrs. ________Mo. _________________________________________________
Hours Per Week:_________
Reason For Leaving: _________________________________________________

school _________________________________________________
Supervisors Name:
________________________________________________

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

Name Complete Address (Include City, State, Zip) Phone Occupation_______
1.
Amy Pellissier 205 W. Olive Ave.
(209) 777-3588
Vice Principal
Merced, CA 95340
________________________________________________________________________________________________________________________________

2. Karen Sizemore 205 W. Olive Ave. (209) 489-1576

Teacher
Merced, CA 95344
________________________________________________________________________________________________________________________________

3. 205 W. Olive Ave. (209) 756-0882

Kurt Smoot
Counselor
Merced, CA 95344
________________________________________________________________________________________________________________________________

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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