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Supplemental Questionnaire

Last Name
First Name
Do you have a valid Psychiatric Technician License issued by the State of California?
Yes No

If you answered "Yes" to the above question, please provide your license number and expiration date.


Do you have two (2) years of full-time paid experience performing the duties of a psychiatric technician or mental health technician in a mental health facility?

Yes No

If you answered "Yes" to the question above, please describe your paid experience as a licensed psychiatric technician in detail. Provide the name of the your employer, your duties, the start/end date, and hours/week you worked.