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#19-004292-0001
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 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
 

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.

2.

Have you applied for, and are pending a license as a Registered Nurse from the Maryland State Board of Nursing?

Yes No
3.

Please your experience coordinating and supervising across multiple work sites/locations. Please describe this experience including dates, place(s) of employment and number of hours per week these duties were performed. If you do not possess this experience please write N/A.

4.

Please describe your experience coordinating and supervising across multiple secure residential juvenile facilities/settings. Please describe this experience including dates, place(s) of employment and number of hours per week these duties were performed. If you do not possess this experience please write N/A.


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