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#19-001563-0005
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 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.


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