Official SealSan Joaquin County Human Resources Division


#0320-RH1300-01
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a Bachelor's degree in Nursing, Health Science, Business Administration or other closely related field?
Yes No
 

Please provide the following information:

  • Name of college or university from which you graduated;
  • Degree obtained; 
  • Major 
2.

Do you possess a current registration as a nurse in the State of California? 
Yes No
 

If you answered yes to the above question, please identify the following:

  • License number
  • Date of expiration
3.

Do you have four years of progressively responsible experience as a registered nurse in an Intensive Care Nursery including one year of full-time supervisory or charge experience?
Yes No
 

If yes, please detail your experience including:

  • Dates of employment (from - to)
  • Position title(s)
  • Employer(s)
  • Duties performed
  • Supervisory duties performed

Identify the requested above information for each relevant position you held.