ROP APPLICATION

Directions: Please Print Legibly

Garcia
Laura
Alejandra
Name: __________________________________________

(Last)

(First)

8 February 2016
____________________

(Middle)

Date

Po Box 1501
Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95340
_______________________________________________________________________________

(City)

(State)

( 209 ) 355-8503

(Zip Code)

pinklaura1584@gmail.com
354-0072
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

(Telephone Number)

Occupational Therapist
Position applied for:_______________________________________________________________

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

I communicate well with others and I adjust to my surrounding realy quick and im not afraid of a challenge

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

High School

Name of School

City/State

Merced High School

Merced/CA

Course of
study or
major

College/
University

Last year
completed

Did you
graduate?

Diploma
or degree

1 2 3 4

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:

FULL TIME

AVAILABILITY
SUNDAY

MONDAY

TUESDAY

WEDNESDAY

8:00am-6:00pm 4:00pm-7:00pm4:00pm-7:00pm 4:00pm-7:00pm

THURSDAY

FRIDAY

PART TIME

SATURDAY

4:00pm-7:00pm 4:00pm-7:00pm8:00am-6:00pm

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Title__________________________Last Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

______

______

Mo / Yr

Mo/Yr

Total ____Yrs. ________Mo.

_________________________________________________
Hours Per Week:_________
Reason For Leaving:

From:

_________________________________________________
Supervisors Name:
_____________________________________________________

_________________________________________________

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.

Andrea Deleon

Complete Address (Include City, State, Zip)

205 W Olive Ave, Merced, CA 95348

Phone

(209)777-2496

Occupation_______

Teacher

________________________________________________________________________________________________________________________________
2.

________________________________________________________________________________________________________________________________
3.

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________

N:\ROP\Charlotte Klock\ROP Forms\Forms\ROP Job Application with availbility back-for fillable.rtf

Revised 7/10