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#18-004287-0001
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.

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
2.

Please provide your license number and expiration date 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.

Describe your supervisory, teaching or administrative experience in nursing, including dates and hours worked. If none, enter "N/A".
5.

Do you possess a Bachelor's degree in Nursing or a related field from an accredited college or university?
Yes No
6.

Do you possess a Master's degree in Nursing or a related field from an accredited college or university?
Yes No

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