ROP APPLICATION

Directions: Please Print Legibly

Vang Faith Pahoua
Name: __________________________________________

(Last)

(First)

7 May 2014
____________________

(Middle)

Date

3430 LaJolla Drive

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
Merced
95348
_______________________________________________________________________________

(City)

(209 ) 631-9864

(State)

(Telephone Number)

(Zip Code)

faithpvang7@yahoo.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

Position applied for:_______________________________________________________________

Nurse Aide
Skills and/or competencies which qualify you for this position:
Independent, Responsible, Humble, Patient, Quick to learn and listen, Quick to respond in action, etc.

Hmong
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

City/State

Merced High School

Course of
study or
major

Merced, CA

College/
University

General
Studies

Last year
completed

Did you
graduate?

Diploma
or degree

1 2 3 4

Pending

High
School

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
ROP Medical, Anatomy, Biology, Chemistry and Health

FULL TIME

AVAILABILITY
SUNDAY

MONDAY

TUESDAY

1pm-7pm

1pm-7pm

WEDNESDAY

PART TIME

THURSDAY

FRIDAY

1pm-7pm

1pm-7pm

SATURDAY

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Mercy Medical Volunteer

Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

To:

10/12
______

10/13
______

Mo / Yr

Mo/Yr

1
Total ____Yrs.
________Mo.
4
Hours Per Week:_________
Reason For Leaving:
Done with hours required

From:

333 Mercy Ave.

Welcome Guests and patients who enter the

hospital, guide visitors, answer the lobby desk
phone

4/13
______

Mo/ Yr

Mo/Yr

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

Merced, CA 95340

_________________________________________________
_________________________________________________

Supervisors Name:
Jan Sorge
_____________________________________________________

_________________________________________________

Title__________________________Last
Salary: _____________
Nurse Aide

_________________________________________________

Duties:

_________________________________________________

Assist supervisor, assist patients and their needs,

record patients vital signs

_________________________________________________

To:

1/13
______

Mercy Medical Center

Mercy Medical Center

333 Mercy Ave.

Merced, CA 95340

_________________________________________________

Done with required time

_________________________________________________
Supervisors Name:
Connie Clifford
________________________________________________

From:

To:

2005
______

present
______

Mo /Yr

Mo/Yr

10
Total ____Yrs.
________Mo.
6
Hours Per Week:_________
Reason For Leaving:

Golden Valley High School

Babysitter
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Supervise whose whild is brought into the daycare

area, provide food for the children

_________________________________________________

2121 E. Childs Ave.

Merced, CA 95340

_________________________________________________

Supervisors Name:
Jerry Fragrasso
________________________________________________

_________________________________________________

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

Name
1.

Jan Sorge

Complete Address (Include City, State, Zip)

333 Mercy Ave.

Phone

Occupation_______

209-769-1884
Supervisor

Merced, CA 95340

________________________________________________________________________________________________________________________________
2.

Connie Clifford

333 Mercy Ave.

209-564-5683
Supervisor

Merced, CA 95340

________________________________________________________________________________________________________________________________
3. Jerry

Fragasso

2121 E. Childs Ave.

559-917-8148

Merced, CA 95340

ROP Instructor

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________