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ROP APPLICATION
Directions: Please Print Legibly

Name: __________________________________________
Slagter Juliana D. ____________________
April, 2016
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

3081 Coppertree Ct.
(P.O. Box or Street Number)

Merced California 95340

_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 628-2210 ( 209 )____________________

768-2298 ____________________________
jslagter104127@muhsdstudents.org
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

Registered Nurse

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, MS Word & other medical office skills.

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
_______________________
Y2273938
(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 Merced, CA general pending

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:

Golf, Junior Fair Board, Dare-2-Care. Courses: AP Government, Statistics, AP Literature and Composition,
Floral Design, Teacher's Aid.

FULL TIME
AVAILABILITY PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

n/a after 2:07 after 2:07 after 2:07 after 2:07 after 2:07 10a-6p
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, 4th floor.
_________________________________________________
02/16
______ 05/2016
______
Mo / Yr Mo/Yr
Duties
333 Mercy Ave.
_________________________________________________
0
Total ____Yrs. 0
________Mo.
Vital signs, filing, patient histories, patient transfers, Merced, CA 95340
_________________________________________________
4.5
Hours Per Week:_________ etc.
Reason For Leaving: (209) 564-5400
_________________________________________________
course ended
Supervisors Name: _________________________________________________
Rachel Abril, RN
_____________________________________________________

From: To:
$10/hour various
babysitter
Title__________________________Last Salary: _____________ _________________________________________________
01/12
______ current
______
Mo/ Yr Mo/Yr Duties: _________________________________________________
6
Total ____Yrs. 1
________Mo. Babysit children, cook dinner, lunch, or breakfast for _________________________________________________
n/a
Hours Per Week:_________ them
Reason For Leaving: _________________________________________________

n/a _________________________________________________
Supervisors Name:
various
________________________________________________

From: To:
Cleaning Lady
Title___________________________Last $50
Salary: ____________
Maid
_________________________________________________
06/15
______ 02/16
______
Mo /Yr Mo/Yr Duties:
2623 Santa Cruz Ct.
_________________________________________________
0
Total ____Yrs. 8
________Mo. Clean and vacuum the living room, Atwater, CA, 95301
_________________________________________________
n/a
Hours Per Week:_________ clean/sweep/mop the kitchen, clean the bathroom (209) 777-4843
Reason For Leaving: _________________________________________________

Boss couldn't afford to pay _________________________________________________

me. Supervisors Name:
Paulette Kuerz
________________________________________________

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. John Kane 1738 A St. (209)261-9292

Golf coach
Merced, CA 89755
________________________________________________________________________________________________________________________________

3. 2354 Santa Cruz Ct. (209)777-4553

Paulette Kuerz
Boss
Atwater, CA 12356
________________________________________________________________________________________________________________________________

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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