Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


The following Licenses/Certifications are all required to qualify for this position: RN License, Nurse Practitioner Certification and current Furnishing License all with the CA Board of Registered Nursing. Please provide the license/certification number for each so that it can be source verified by Human Resources. If you do not possess the license/certification, please note "N/A" in the text box:


California Registered Nurse License:


Nurse Practitioner Certification Number:


Furnishing License Number:


Education: Have you completed an approved Nurse Practitioner training program at an accredited college or university or certified program?

If yes, identify that following:

  • Name of educational institution in which you attended
  • Type of degree/certificate awarded

Do you possess National Certification? If yes, identify below the certification number and speciality area.



Experience: Do you possess four years experience as a Nurse Practitioner? If yes, identify the following:

  • Name of employer
  • Position title
  • Duties performed
  • Timeline of employment


Experience: Do you possess five years experience as a Nurse Practitioner and specialty certificates for training such as colposcopy, diabetes education or other specialty training?  If yes, identify that following:

  • Name of employer
  • Position title
  • Duties performed
  • Specialty certificates possessed
  • Timeline of employment

In order to practice at San Joaquin County Clinics, must be credentialed and granted privileges through the San Joaquin County Clinics Credentials Committee within ninety (90) days of appointment and in accordance with departmental bylaws and state regulations. New employees may be granted temporary privileges by the SJCC Chief Medical Officer or designee, pending Credentials Committee approval; 2) Eligible incumbent may be certified only to job vacancies in the area of specialization in which they possess specialized education and certification. Additionally, the successful completion of approved nursing training programs, possession of specific nursing experience or the possession of specified professional certificates may be required depending on the nature of the area of assignment.

Have you read and acknowledge the above? 

Yes No