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ROP APPLICATION
Directions: Please Print Legibly

Name: __________________________________________
Cooksey Tateanna Shanelle ____________________
March 22, 2017
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

3638 San Onofre Ave
(P.O. Box or Street Number)

Merced CA 95348
_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 683-6343 ( 209 )____________________

354-4443 ____________________________
tateanna.cooksey@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, EKG, MS Word, Excel, and spreadsheet. Taking
care of a g-tube and giving breathing treatments.

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
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 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:

Courses: ROP Medical Technologies, Chemistry, 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, ER
_________________________________________________
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
_________________________________________________
4.5
Hours Per Week:_________ etc.
Reason For Leaving: (209) 564-5400
_________________________________________________
n/a
Supervisors Name: _________________________________________________
Philip Brown
_____________________________________________________

From: To:
$20/week Tamara Cooksey
babysitter
Title__________________________Last Salary: _____________ _________________________________________________
07/13
______ current
______
Mo/ Yr Mo/Yr Duties:
3638 San Onofre Ave
_________________________________________________
3
Total ____Yrs. 2
________Mo. Merced, CA 95348
Responsible for the health and well being of a 3 yr _________________________________________________
56
Hours Per Week:_________ old with Celiac disease and down syndrome. Also 209-683-6343
Reason For Leaving: giving him breathing treatments and medicine. _________________________________________________

n/a _________________________________________________
Supervisors Name:
Tamara Cooksey
________________________________________________

From: To:
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.
Jerry Fragasso 2121 E. Childs Ave.
(559) 917-8148
ROP Instructor
Merced, CA 95341
________________________________________________________________________________________________________________________________

2. Patricia Zarco 205 W. Olive Ave. (209) 756-2685

Counselor
Merced, CA 95344
________________________________________________________________________________________________________________________________

3. 1971 Pebble Beach Dr. (209) 617-9801

Jill Stubbs
Advisor
Merced, CA 95340
________________________________________________________________________________________________________________________________

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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