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#19-004216-0071
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
2.

Please provide your license number and expiration date OR the date you will be sitting for the exam. Not providing this information may result in disqualification.
3.

Describe your phlebotomy experience.  Include name of employer, job title, dates employed, and hours worked per week.   If you do not have this experience, please indicate N/A.
4.

Bilingual applicants are encouraged to apply.

Are you able to speak, read and write in both English and another language?
Yes No

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