ROP APPLICATION

Directions: Please Print Legibly

Gonzalez
Karen
Heidi
Name: __________________________________________

(Last)

(First)

04/15/15
____________________

(Middle)

Date

3276 Juneau Court

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95348
_______________________________________________________________________________

(City)

(209 )

(State)

(Telephone Number)

(Zip Code)

)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Internship
Skills and/or competencies which qualify you for this position:
Responsible, reliable, able to multitask in a timely manner.

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
High
School
Dipl
Bachelor
of Science

Merced High School

Merced CA

General Ed.

1 2 3 4

2015

Brigham Young
University-Idaho

Idaho

Public
Health

1 2 3 4

2019

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Junior Statesmen of America, Tennis Club, Girls Varsity Tennis, M.E.CH.A.

FULL TIME

AVAILABILITY
SUNDAY

PART TIME

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

7am-8pm

7am-8pm

7am-8pm

7am-8pm

7am-8pm

7am-8pm

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Student Volunteer
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Cerical work, discharge patients, work in the lab,

help the nutritionists.

_________________________________________________

To:

04/12
______

07/14
______

Mo / Yr

Mo/Yr

4
3
Total ____Yrs.
________Mo.
4
Hours Per Week:_________
Reason For Leaving:

From:

333 Mercy Ave. Merced CA, 95340

209-564-5000

_________________________________________________
Supervisors Name:
Jan Sorge
_____________________________________________________

_________________________________________________

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.

Jan Sorge

Complete Address (Include City, State, Zip)

333 Mercy Ave. Merced CA 954340

Phone

Occupation_______

209-564-5000
Student Supervisor

________________________________________________________________________________________________________________________________
2. Lynda

Dyas

3476 Monte Grosso Merced CA 95340

209-756-0530
Mentor

________________________________________________________________________________________________________________________________
3. Keith

Tetancgo

205 West Olive Ave. Merced CA 95340

209-384-6465
Tennis Coach

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________