**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
Are you currently licensed to practice medicine by the Maryland Board of Physicians? (If Yes, please submit a copy of your license or license verification with your application.)
Yes
No
2
If you answer no to the question above, do you possess a license to practice medicine in another state?
If yes, please list the state and license number.
3
Do you possess a current Maryland Controlled Dangerous Substance Registration?
Yes
No
4
Do you possess board certification in psychiatry?
Yes
No
5
Do you possess Board Certification in Forensic Psychiatry?
Yes
No
6
Describe your experience managing health service operations in a behavioral health care setting.
Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application. If you do not possess experience in this area, put N/A in the box below.
7
Describe your experience at the supervisory or managerial level.
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.
8
Describe your experience in forensic health service program planning and development.
Please include name of employer, job title, dates of employment, and hours worked per week. This information must also be reflected in your application. If you do not possess experience in this area, put N/A in the box below.
Department of Budget and Management