Official SealSan Joaquin County Human Resources Division


#1022-RH1105-PC
Supplemental Questionnaire

Last Name
First Name
1.

Are you currently registered as a nurse in the State of California?
Yes No
 

If yes, please list your license number and expiration date:
2.

Education:

Do you possess a Bachelor's degree? (Note: If yes, please make sure it is clearly identified on your employment application under education or resume).
Yes No
 

If yes, please list

  • Type of degree (i.e. bachelors, masters, etc.)
  • Major course of study
  • Name of college or university
3.

Please indicate if you possess any of the following certifications:

Verification of certifications is required. Please upload copies of all certifications when prompted to upload a Resume.
ACLS
PICC Certification
Chemotherapy Certification or a course acceptable to the Director of Nursing Services
PALS
NRP
PM&R Class
Critical Care Class
ED Essentials
Other
 

If "Other", please list certificate: