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#19-001566-0002
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 currently possess a license as a Certified Professional Counselor-Alcohol and Drug OR Licensed Clinical Alcohol and Drug Counselor from the Maryland Board of Professional Counselors and Therapists?

Yes No
2.

If you answered Yes to question 1, please provide your license number and expiration date in the box below.  If No, please enter N/A in the box below.


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