Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


Please complete the following supplemental questionnaire. This questionnaire is considered an extension of your employment application and will be reviewed to help assess your qualifications. Resumes are not accepted in lieu of completing this questionnaire.


This position requires a valid license as a Registered Nurse issued by the State of California Board of Registered Nursing.  Provide your license number and expiration date.


Do you possess a valid California Public Health Nursing Certificate?

Yes No

If you answered Yes, please provide your Public Health Nursing Certificate number and expiration date.


If you answered Yes, you must provide verification with your employment application that an application for Public Health Nurse certification has been submitted and is pending with the California Board of Registered Nursing. Please either attach verification to your application or submit via email to


This position requires possession of a valid California driver's license.  Please provide your license number and expiration date.


This recruitment may be used to fill part-time and/or temporary positions, in addition to the full-time vacancies.

Please mark any and all you are being interested in being referred for: