Official SealHuman Resource Services Department

Supplemental Questionnaire

Last Name
First Name

IMPORTANT:  Applicants for this position are required to submit responses to the following supplemental questions. 

By selecting yes below, you certify your understanding that all applicants must meet minimum qualifications in order to move forward in the process.  Do you understand the above statement?

Yes No

By selecting yes below, you certify your understanding of the following:

  • Candidates who possess the minimum qualifications for the class will be placed directly on the eligible list based on an evaluation of education, training, and experience only;
  • This recruitment may be reopened as necessary and the names of additional candidates merged onto the existing list according to an evaluation of their application material.
Yes No

Please list any state license(s), certificate(s), and/or registration(s) you possess which qualify you for the position of Registered Nurse II (PHN Option). Please indicate license/certificate/registration number, issuance date, and expiration date for each.


In the space provided below, please describe any additional job-related training and/or education you possess beyond that required by the minimum qualifications.


Do you claim veterans’ preference points?

Yes No

Do you claim veterans’ service connected disability points?

Yes No

I understand that to claim veterans’ related preference points, I MUST attach a copy of honorable discharge (DD-214) verification to my application material.  I further understand that if I claim service-connected disability, I MUST also attach proof from the Veteran’s Administration of current disability of 10% or more.

Yes No