Official SealSan Joaquin County Human Resources Division


#0121-RS2011-AC
Supplemental Questionnaire

Last Name
First Name
1.

To qualify, applicants must have graduated with a master's degree or doctorate from an accredited college or university.  Please indicate if you possess a master's degree in one of the following disciplines:
Master's - Social Work
Masters - Counseling
Masters - Psychology
Doctorate - Psychology
Other (specify in question #2)
none of the above
2.

Provide the name of the accredited college/university attended.

If you selected "other" in question #1, include the discipline/field for which you obtained your Master's degree.
3.

Candidates must have the ability to obtain registration with the State of California Board of Behavioral Sciences (BBS) within the first year of employment.  Do you meet the criteria to submit an application to the BBS for registration as an Associate Clinical Social Worker (ASW), Associate Marriage and Family Therapist (MFT), or Professional Clinical Counselor Intern (PCCI)?
Yes No
3a.

If already registered with BBS, please provide your registration number and expiration date.
4.

Candidates must possess and maintain a valid California Driver's License.  Provide your valid California driver's license number and expiration date.
5.

Please indicate if you are willing to work the following shifts:  (Note: You may select more than one category)
Days Only
Nights
Rotating
Graveyards
None of the Above