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#20-004416-0001
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 four (4) years of supervisory or administrative experience in emergency medical services, public safety, law enforcement or licensing activity?

Yes No
2

How many years of supervisory or administrative experience in emergency medical services, public safety, law enforcement or licensing activity do you possess? Select one of the following.

Less than 4 years
4 to 7 years
8 years or more
None of the above
3

Please describe your supervisory or administrative experience in emergency medical services, public safety, law enforcement or licensing activity. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, indicate N/A in the box below.

4

Do you possess a current certification in the Critical Care Emergency Medical Transport Program (CCEMTP)?

Yes No
5

Do you possess a current Maryland Emergency Medical Technical-Intermediate (EMT-I), or Emergency Medical Technical-Paramedic (EMT-P) license?

Yes No

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