Official SealSan Joaquin County Human Resources Division


#1018-RH1124-TM
Supplemental Questionnaire

Last Name
First Name
1

Are you currently registered as a nurse or possess an interim permit issued by the State of California Board of Registered Nursing?

Yes No
2

Please provide your RN or interim permit license number.

3
Do you possess a Bachelors Degree in Nursing or related field?
Yes No
4

If you responded yes, please identify the name of the college or university attended and the major the Bachelor's degree was awarded.

5

Experience:

Do you possess two (2) years of progressively responsible experience as a registered nurse in an acute care setting at a level equivalent to a San Joaquin County Staff Nurse III?

Yes No
6

If you responded yes, please identify:

  • Your job title and duties and responsibilities
  • Employer name/address
  • Your dates of employment
  • Number of hours worked per week