Official SealDepartment of Budget and Management


#19-001563-0004
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a current license as a Certified Associate Counselor-Alcohol and Drug (CAC-AD) from the Maryland Board of Professional Counselors and Therapists?
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.

Are you available to work a minimum of two (2) nights per week?
Yes No

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