Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


Do you possess a Bachelor's Degree or Master's Degree in Nursing or closely-related field. (If a closely-related field, please be sure to clearly indicate the type of degree in the "education" portion of your employment application.)

Bachelor's Degree in Nursing
Master's Degree in Nursing
Bachelor's or Master's in closely-related field


Provide your current RN License Number so that it can be source verified with the State of California Board of Registered Nursing. If you do not possess a valid or current RN License, please note "N/A":


The following section will be utilized to determine if you possess the license and/or certifications required to qualify as a Staff Nurse IV for a specific inpatient unit.  Copies may be attached to your online application, emailed to, or faxed to (209) 468-0508 ATTN: A. Handelman.

Please indicate if you possess any of the following certificates:

Preceptor course or Nursing training certificate
Chemotheraphy certification
National certifications (CEN, CCRN, CNN, CDN, CPAN, CNOR, PCCN)
None of the above

If other was selected, identify the licenses and/or certificates.


Please describe your experience as a Registered Nurse in an acute care hospital unit.  Include the following:

  1. Employer, and type of unit (ICU, PCU/step down, medical surgical, ER, etc)
  2. Job Title
  3. Dates of employment (from/to)
  4. Brief summary of the specific nursing duties performed