Official SealSan Joaquin County Human Resources Division


#0523-RH1105-AC
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
3.

Do you possess at least three years of experience as a journey level registered nurse in an acute care or mental health facility? (Note: One year of the required experience may be substituted with a qualifying Bachelor's Degree)

Yes No
4.

Please indicate if you possess any of the following certificates (check all that apply):

BLS
ACLS
PALS
National Certification (CCRN, etc.)
Preceptor Training Certificate
Critical Care Certificate
Other
 

If "Other", please list certificate: