Official SealSan Joaquin County Human Resources Division


#0918-RH6402-TM
Supplemental Questionnaire

Last Name
First Name
1.

Do you currently possess licensure as a Speech Pathologist issued by the California Speech-Language Pathology and Audiology and Hearing Aid Dispensers' Board?

Yes No
 

If you answered yes to question #1, identify your license number and date of expiration.

2.

Do you possess a Certificate of Clinical Compency in Speech Pathology issued by the American Speech-Language-Hearing Association?

Yes No
 

If you answered yes to question #2, identify your certificate number and the expiration date.