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#18-002586-0081
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

Describe your professional or administrative experience in behavioral health treatment services.

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.

2

Please explain your experience working with inmates or arrested persons.  Please include the name of the employer for whom these tasks were performed, dates of employment.  If you do not have this type of experience,  please write N/A.

3

Do you possess a professional license or certification from a Maryland or other State Board, Commission or professional licensing body (i.e., LMSW, LCSW-C, LGPC, LCPC)?  If so, please indicate the type of license, license number and expiration date below AND upload a copy of license to application.

4

This position involves frequent travel throughout the facilities across the State of Maryland.  Are you willing to perform this duty?

Yes No

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