ROP APPLICATION

Directions: Please Print Legibly

Name: __________________________________________
Perez Celina ____________________
March 22, 2017
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

1137 I street
(P.O. Box or Street Number)

Merced CA 95341
_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 631-2766 ( 209 )____________________

726-3019 ____________________________
perezcelina06@gmail.com
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

nursing aide

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

CPR/first aid, knowledge of vital signs, medical terminology, basic pharmacology, blood borne pathogens
training, HIPAA training, OSHA training, patient transfers, gait training, MS Word, Excel, and medical office
skills including scheduling, phone etiquette, translating, etc.

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
_______________________
V1234567
(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 School Merced, CA general Pending
June 2017
College/ 1 2 3 4
University Merced College Merced, CA nursing 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:

Courses: ROP Medical Technologies, physics, biology, AP English, Spanish

FULL TIME
AVAILABILITY PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

10:00a-6:00p after 3:00p after 3:00p n/a after 3:00p after 3:00p 1:00p-7:00p
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 volunteer
Salary: _____________
Mercy Medical Center, 4th floor
_________________________________________________
01/17
______ current
______
Mo / Yr Mo/Yr
Duties
333 Mercy Ave.
_________________________________________________
0
Total ____Yrs. 3
________Mo.
Vital signs, filing, patient histories, patient transfers, Merced, CA 95340
_________________________________________________
5
Hours Per Week:_________ patient education, scheduling patients, etc.
Reason For Leaving: (209) 564-5400
_________________________________________________
n/a
Supervisors Name: _________________________________________________
Rachel April Nurse, RN
_____________________________________________________

From: To:
$10/day Beatriz Antonio
babysitter
Title__________________________Last Salary: _____________ _________________________________________________
07/13
______ current
______
Mo/ Yr Mo/Yr Duties:
address: N/A
_________________________________________________
3
Total ____Yrs. 7
________Mo. Merced CA, 95340
Responsible for the health and safety of 2 children, _________________________________________________
6
Hours Per Week:_________ ages 3 and 4. Cooking meals, playing with children, phone: (209) 455-0588
Reason For Leaving: change children. _________________________________________________

n/a _________________________________________________
Supervisors Name:
Beatriz
________________________________________________

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

school _________________________________________________
Supervisors Name:
________________________________________________

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 Long 205 W Olive Ave, (209) 325-1000

Teacher
Merced, CA 95348
________________________________________________________________________________________________________________________________

3. 205 W Olive Ave (209) 325-1000

Patricia Zarco
Counselor
Merced, CA 95341
________________________________________________________________________________________________________________________________

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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