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Supplemental Questionnaire

Last Name
First Name

The position requires completion of an accredited training program for Psychiatric Technicians for entrance to testing.

If you have completed a program, provide the name of the institution or college where you completed the program, the date you completed the program, and the name of the program.

Note:  Prior to employment, must possess a valid license as a Psychiatric Technician issued by the California Board of Vocational Nurse and Psychiaric Technician Examiners.

Do you have a valid Psychiatric Technician License issued by the State of California?
Yes No

If you answered yes to question #3, provide your license number and expiration date.