ROP APPLICATION

Directions: Please Print Legibly

Name: __________________________________________
Lopez Patricia Avila ____________________
5/1/17
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

21 W 25th Street
(P.O. Box or Street Number)

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

(209 ) 947-8695 ( )____________________ ____________________________

lopezpatty445@gmail.com
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

Nursing Assistant

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

compassionate, level header, self-control, polite, hands on

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
Course of
study or Last year Did you Diploma
Name of School City/State major completed graduate? or degree
High School Merced High school Merced Ca. General 1 2 3 4 present diploma
Attending
College/ 1 2 3 4
University

Other
1 2 3 4
(Specify)

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Key Club working with children and adults

FULL TIME
AVAILABILITY PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

7-4 7-4 7-4 7-4 7-4 7-4 7-4

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:
Title__________________________Last Salary: _____________ _________________________________________________
______ ______
Mo / Yr Mo/Yr
Duties _________________________________________________
Total ____Yrs. ________Mo.
_________________________________________________
Hours Per Week:_________
Reason For Leaving: _________________________________________________

Supervisors Name: _________________________________________________

_____________________________________________________

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

_________________________________________________
Supervisors Name:
________________________________________________

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

_________________________________________________
Supervisors Name:
________________________________________________

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

Name Complete Address (Include City, State, Zip) Phone Occupation_______
1.
Brent Brewer 126 E. Juniper Ave Atwater Ca 95301 (209) 777-1322
full time student
________________________________________________________________________________________________________________________________

2. Jacob Gomez 1055 Prince William Ct. Atwater Ca 95401 (209) 326-2019
full time stident
________________________________________________________________________________________________________________________________

3. Richard Perez 1864 Brentwood Ca. 95341 (209) 308-2940

Diesl Mechanic
________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________