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#19-008998-0015
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.

Have you earned a doctorate in Pharmacy (PharmD) from an accredited School of Pharmacy?

Yes No
2.

Do you possess a current license as a Registered Pharmacist from the Maryland State Board of Pharmacy?

Yes No
3.

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.

4.

Do you possess certification in a relevant specialty by the Board of Pharmacy Specialties?

Yes No
5.

Please list your certifications below.  Also attach a copy to your application.

6.

Describe your managerial experience below.  Please include name of employer, job title, the titles of those you supervised, types of programs managed, dates employed, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.

7.

Describe your previous experience as a pharmacy administrator. 

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.


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