Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


Are you currently registered as a nurse in the State of California?

Yes No

If yes, please identify your license number and expiration date:

(Note:  A copy of your license needs to be submitted with your application.  You may send it via email to, fax to 209-468-0508, or to Human Resources, 44 N San Joaquin, Ste 330, Stockton 95202)


If you responded no, do you have possession of an interim permit issued by the State of California Board of Registered Nursing?

Yes No

If yes, please identify your interim permit number:



Do you possess 6 months of experience as a registered nurse in an acute care or mental health facility?

Yes No

If yes, please identify your employer (acute care or mental health facility), your title, responsibilities and duties, dates of employment, and hours worked per week:



Possession of a bachelor's degree in nursing may be substituted for the required experience.

Do you possess a bachelor's degree in nursing? (If yes, please make sure it is clearly identified on your employment application under education or resume).

Yes No

If yes, please list the name of the college and/or university you obtained your BSN from: