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#18-004286-0016
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. 


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.

If you responded Yes to question 1, please provide your license number and full expiration date in the box below.  If your license is from a compact state, please provide a copy of your license or license verification.  Enter N/A if this question does not apply to you.
3.

Are you able to work the 3rd shift from 12:00 AM until 8:30 AM?
Yes No

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