Are you currently registered as a nurse in the State of California?
Yes
No
If yes, please list your license number and expiration date:
2.
Education:
Do you possess a Bachelor's degree? (Note: If yes, please make sure it is clearly identified on your employment application under education or resume).
Yes
No
If yes, please list
Type of degree (i.e. bachelors, masters, etc.)
Major course of study
Name of college or university
3.
Do you possess at least three years of experience as a journey level registered nurse in an acute care or mental health facility? (Note: One year of the required experience may be substituted with a qualifying Bachelor's Degree)
Yes
No
If yes, please identify the items below, and include any experience serving as a house supervisor, charge nurse, a preceptor to new nurses or in a leadership capacity:
Name of employer, and the nursing unit that you worked on
Starting & ending dates of employment
Job title & responsibilities
4.
Please indicate if you possess any of the following certificates (check all that apply):