Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name

Please review the following and check all that apply:

I currently possess a Bachelor's Degree in Nursing or related field (Please clearly list degree on education portion of your application).
I have successfully completed a Nurse Practitioner Program.
I possess National Certification. (Must submit proof so that it can be source verified).
I have successfully completed specialty training courses. (Please note that proof of completion must be submitted with employment application in order to be considered).
I have not completed any of the programs listed above.


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:


Do you acknowledge and accept the following:

In order to practice at San Joaquin General Hospital, you must be credentialed and  granted privileges through the San Joaquin General Hospital Committee on Interdisciplinary Practice (CIDP) within ninety (90) days of appointment and in accordance with medical staff bylaws and state regulations.  New employees may be granted temporary privileges by the Medical Director or designee, pending Committee Interdisciplinary Practice approval. Eligibles may be certified only to job vacancies in the area of specialization in which they posses specialized education and certification.  Additionally, the successful completion of approved nursing training programs, possession of specific nursing experience or the possession of specified professional certificates may be required depending on the nature of the area of assignment.

Yes No