ROP APPLICATION

Directions: Please Print Legibly

Name: __________________________________________
Ceja Villano Karina ____________________
4/26/17
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

425 Buena Vista Dr.
(P.O. Box or Street Number)

Merced CA 95348
_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 291-9864 ( 209 )____________________

726-3858 ____________________________
[email protected]
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

Front Office

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

I am familiar with Microsoft word and Excel, CPR, First Aid, HIPAA, Blood Pressure,

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 1 2 3 4
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:

Bilingual, Computer Application, Medical Terminology

FULL TIME
AVAILABILITY PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

6am - 9pm 6am - 9pm 6am - 9pm 6am - 9pm 6am - 9pm 6am - 9pm 6am - 9pm
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:
Front Office Clerk
Title__________________________Last $35.00
Salary: _____________
Tiffany Hosburgh Merced General Surgery, Inc.
_________________________________________________
2/15
______ Recent
______
Mo / Yr Mo/Yr
Duties
3351 M St., Ste. 105 Merced, California 95348
_________________________________________________
Total ____Yrs. ________Mo.
Filing, Computer Excel, (209) 384-8111
_________________________________________________
4
Hours Per Week:_________
Reason For Leaving: _________________________________________________

Supervisors Name: _________________________________________________

Carmen
_____________________________________________________

From: To:
$35.00 3412 Maze Blvd. 95358
Babysitting
Title__________________________Last Salary: _____________ _________________________________________________
2/15
______ Recent
______
Mo/ Yr Mo/Yr Duties:
(209)634-7253
_________________________________________________
Total ____Yrs. ________Mo. Feeding, Showering, Caring, Changing diapers _________________________________________________
6hrs
Hours Per Week:_________
Reason For Leaving: _________________________________________________

_________________________________________________
Supervisors Name:
Ana Villano
________________________________________________

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

N/A _________________________________________________
Supervisors Name:
N/A
________________________________________________

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

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

2. Tiffany Williams 205 W Olive Ave, Merced, CA 95348 (408)278-3582

English Teacher
________________________________________________________________________________________________________________________________

3. 205 W Olive Ave, Merced, CA 95348 (209)234-8936

Isable Rodriguez
Spanish Teacher
________________________________________________________________________________________________________________________________

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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