Official SealSan Joaquin County Human Resources Division


#1022-RH2001-TC
Supplemental Questionnaire

Last Name
First Name
1.

Possession of a valid license as a Vocational Nurse issued by the State of California, Board of Vocational Nurse and Psychiatric Technician Examiners; or possession of a valid interim Permit issued by the Board is required.

Check mark below what you possess:
I possess a valid Vocational Nurse License.
I possess a valid Vocational Nurse Interim Permit.
I do not possess a valid Vocational Nurse License or Interim Permit.
2.

Please provide your license number or interim permit number below: