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#18-004214-0001
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 bachelor’s degree from an accredited college or university in one of the following fields: counseling, education, nursing, occupational or physical therapy, psychology, social work, sociology, speech pathology, audiology or therapeutic recreation?

Yes No
2.

In which field of study is your degree? If you do not have a degree, enter N/A.

3.

Describe your experience providing professional services to the developmentally disabled. 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. 


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