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#18-004231-0001
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 currently possess a certification as a Dental Hygienist from the Maryland Board of Dental Examiners?  (A copy of you license or license number must accompany your application)
Yes No
2.

If you answered Yes to Question 1, please provide your certification number and complete expiration date in the space below.  If not applicable, put N/A in the space below.
3.

Do you have experience as a Dental Hygienist working with children?
Yes No
4.

If you responded YES to the above question, please describe your experience as a Dental Hygienist working with children.  This experience should also be included in your application.

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