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#24-004394-0005
Supplemental Questionnaire

Last Name
First Name

 

**Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1

Describe your clerical experience applying policies in a medical care, health insurance or Federal or State entitlement program.

Please include name of employer, job title, dates of employment, and hours worked per week.  If you do not possess experience in this area, put N/A in the box below.

2
Are you bilingual in Spanish and English?
Yes No
3

Describe your experience providing English and Spanish interpretation and translation services.  This experience should also be included in your application.  If you do not possess this type of experience, please indicate N/A in the text box.

4

Describe your experience with reviewing, processing and the verification of eligibility applications.

This experience should be included on your application, including hours and dates worked. If you do not possess this type of experience, please put N/A in the text box.


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