Official SealSan Joaquin County Human Resources Division


#0819-RH1811-01
Supplemental Questionnaire

Last Name
First Name

 

Please complete the following supplemental questionnaire. This questionnaire is considered an extension of your employment application and will be reviewed to help assess your qualifications. Resumes are not accepted in lieu of completing this questionnaire.


1.

This position requires a valid license as a Registered Nurse issued by the State of California Board of Registered Nursing.  Provide your license number and expiration date.

2.

Do you possess a valid California Public Health Nursing Certificate?

Yes No
 

If you answered Yes, please provide your Public Health Nursing Certificate number and expiration date.

2a.

If you answered No, have you submitted a Public Health Nursing Certificate application to the California Board of Registered Nursing?

Yes No

 

If you answered Yes, you must provide verification with your employment application that an application for Public Health Nurse certification has been submitted and is pending with the California Board of Registered Nursing.


3.

This position requires possession of a valid California driver's license.  Please provide your license number and expiration date.