Official SealSan Joaquin County Human Resources Division


#0123-RH1123-AC
Supplemental Questionnaire

Last Name
First Name
1.

Are you currently licensed as a Registered Nurse in the State of California?
Yes No
 

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

If you responded No to Question 1, do you have possession of an interim permit issued by the  State of California Board of Registered Nursing?
Yes No
 

If yes, please provide your interm permit number and expiration date.
3.

Do you have six months of experience as a Registered Nurse in an acute care or mental health facility?
Yes No
 

If yes, please list employer, indicate if it was an acute care or mental health facility, dates of employment, your title, and responsibilities and duties.  If experience was part-time, please provide number of hours worked per week.
 

Possession of a bachelor's degree in nursing may be substituted for the required experience.  Do you possess a bachelor's degree in nursing from an accredited college or university?
Yes No

 

If yes, please make sure it is clearly identified on your employment application.