Official SealSan Joaquin County Human Resources Division


#0524-RH1167-AC
Supplemental Questionnaire

Last Name
First Name

1.

The following Licenses/Certifications are all required to qualify for this position: RN License, Nurse Practitioner Certification and current Furnishing License all with the CA Board of Registered Nursing. Please provide the license/certification number for each so that it can be source verified by Human Resources. If you do not possess the license/certification, please note "N/A" in the text box:
 

California Registered Nurse License:
 

Nurse Practitioner Certification Number:
 

Furnishing License Number:
2.

Do you have a Bachelor's Degree in Nursing or a related field?
Yes No
3.

Have you completed an approved Nurse Practitioner training program at an accredited college or university, or another approved certified program?
Yes No

 

Please ensure this is CLEARLY indicated in the Education section of your application.
4.

Do you possess National Certification? If yes, identify below the certification number and speciality area.
5.

How many years of full-time Nurse Practitioner experience do you have? 
Less than four years
Four years or more
Five years or more

 

If yes, please ensure this is CLEARLY demonstrated in the Employment Experience section of the application.