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Supplemental Questionnaire

Last Name
First Name
1.

Have you completed an approved Nurse Practitioner training program at an accredited college or university, or another approved certified program?
Yes No

 

Please ensure this is CLEARLY indicated in the Education section of your application.
2.

Are you currently registered as a nurse and certified as a Nurse Practitioner in the State of California?
Yes No
3.

Do you currently possess a furnishing license through the State of California, Board of Registered Nursing, or have the ability to obtain the State of California, Board of Registered Nursing furnishing license within one (1) year of employment?
Yes No

 

Please ensure this is CLEARLY indicated in the Professional Licenses, Certifications, or Registrations section of your application. 
4.

By checking this box, I acknowledge that:

1) In order to practice at San Joaquin General Hospital, I must be credentialed and granted privileges through the San Joaquin General Hospital Committee on Interdisciplinary Practice (CIDP) within ninety (90) days of appointment and in accordance with medical staff bylaws and state regulations.

2) I may be granted temporary privileges by the Medical Director or designee, pending Committee Interdisciplinary Practice approval.

3) I may be certified only to job vacancies in the area of specialization in which I possess specialized education and certification.