ROP APPLICATION

Directions: Please Print Legibly

Name: __________________________________________
Bolden Tyeisha Monet ____________________
March 4, 2016
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

P.O. Box 3502
(P.O. Box or Street Number)

Merced Ca 95344
_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 354-1010 ( 209 )____________________

421-9546 ____________________________
[email protected]
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

nursing aide

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

Certified in OSHA and HIPAA, knowledgeable of the blood borne pathogens and medical terminology, Vital
Signs, BLS trained, first aid training

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
_______________________
Y2644073
(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
June 2018
College/ 1 2 3 4
University Fresno State Fresno, 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, Chemistry, AP English, Spanish, Computer Applications,

FULL TIME
AVAILABILITY PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

after 2pm after 3pm after 3pm after 3pm n/a after 3pm anytime
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: _____________
University Surgery Center
_________________________________________________
03/16
______ 05/16
______
Mo / Yr Mo/Yr
Duties
1390 E Yosemite Ave B, Merced, CA 95340
_________________________________________________
0
Total ____Yrs. 4
________Mo.
take patients vital signs, assist in patient transfers, (209)259-2837
_________________________________________________
5
Hours Per Week:_________ knowledgeable in patient history
Reason For Leaving: _________________________________________________
end of ROP class
Supervisors Name: _________________________________________________
_____________________________________________________

From: To:
Babysitting
Title__________________________Last $10/hr
Salary: _____________ _________________________________________________
01/15
______ 10/15
______
Mo/ Yr Mo/Yr Duties:
1555 Hourglass Ave Merced, CA 95348
_________________________________________________
0
Total ____Yrs. 10
________Mo. (209)756-4410
Cater to the child; feed, entertain, settle down, etc. _________________________________________________
10
Hours Per Week:_________ one little girl, age: 8
Reason For Leaving: _________________________________________________

no longer needed a baby _________________________________________________

sitter Supervisors Name:
Danny
________________________________________________

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

_________________________________________________
Supervisors Name:
________________________________________________

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

Name Complete Address (Include City, State, Zip) Phone Occupation_______
1.
Stacy Guerra 1617 Main St, Livingston, CA 95334
(209) 947-1263
School Nurse
________________________________________________________________________________________________________________________________

2. Joel Garcia 205 W Olive Ave, Merced, CA 95348 (209)658-1977

Sports Coach
________________________________________________________________________________________________________________________________

3. 127 W El Portal Dr B, Merced, CA 95348 (209)600-1158

Yolanda Sanchez
Front Desk Clerk
________________________________________________________________________________________________________________________________

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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