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#19-004284-0007
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 OR will you be sitting for the licensing exam within the next 90 days?

Yes No
2.

Please provide your license number, expiration date and state (if it is a compact state) OR the date you will be sitting for the exam. Not providing this information may result in disqualification.

3.

If you wish to be placed on the list as pending license, please indicate below the approximate date that you intend to receive the license, and the reason for the delay.  (ex. licensed in another state, awaiting results of the exam)


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