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#18-004291-0001
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.

This recruitment is for two shifts.  The first is for Day Shift (7 am to 3:30 pm), which is required to rotate shifts as needed.  The second is for the Evening Shift (3 pm to 11:30 pm).  Please select the shift(s) in which you are willing to work. 

Day Shift (7 am to 3:30 pm), with rotating shifts as needed
Evening Shift (3 pm to 11:30 pm)
2.

Describe your experience as a Registered Nurse in a supervisory, administrative or consultative capacity.

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. 

3.

Please describe your experience working as a Registered Nurse in a Psychiatric setting.  Include dates and hours worked per week.  If you do not possess experience in this area, put N/A in the box below.

4.

Do you possess a current license as a Registered Nurse from the Maryland State Board of Nursing, or a license recognized by the Multi-State Compact agreement?

Yes No
5.

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.


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