Official SealSan Joaquin County Human Resources Division


#0319-RH6202-AC
Supplemental Questionnaire

Last Name
First Name
1

Do you possess a current licensure as a Speech Pathologist issued by the California Speech-Language Pathology and Audiology and Hearing Aid Dispensers’ Board and a Certificate of Clinical Competency in Speech Pathology issued by the American Speech-Language-Hearing Association.
Yes No
 

If yes, identify the license number and certificate number and expiration dates for both the license and the certificate.