Official SealSan Joaquin County Human Resources Division


#0822-RH1124-FL
Supplemental Questionnaire

Last Name
First Name
1.

Please select the level of Staff Nurse at which you would like to be considered:
Staff Nurse III - AMB
Staff Nurse IV - AMB
Both
2.

Do you possess a current valid California Registered Nurse license?
Yes No
3.
Do you possess a Bachelors Degree in Nursing or related field?
Yes No
4.

How many years of experience do you have as a licensed Registered Nurse?
Less than 1 year.
1 to 2 years.
3 years or more.
5.

Please select any certifications that may apply to you:
EKG
ACLS
PALS
Preceptor
National Certification