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#18-000277-0003
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 an Environmental Health Specialist issued by the Maryland Board of Environmental Health Specialists? 

Yes No
2.

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.

3.

Describe your environmental health work experience in the promotion, control, and maintenance of environmental health. 

Please include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This information must also be reflected in your application.  If you do not have this experience, put N/A in the box below.

4.

Do you possess a Master's Degree from an accredited college or university?

Yes No
5.

If yes, please list your field of study.  If no, enter N/A.

6.

Describe your training and experience in food facility inspections. 

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.

Are you willing to travel statewide?

Yes No

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