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#20-009281-0003
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

Are you currently licensed to practice medicine by the Maryland Board of Physicians?  (If Yes, please submit a copy of your license or license verification with your application.)
Yes No
2

If you answered yes, please attach a copy of your license to your application.  Also, provide the license number and expiration date below.
3
Are you Board Certified in Psychiatry? Please submit a copy of your license with your application.
Yes No
4

The desired candidate should be Board Certified in Addiction Medicine or Addiction Psychiatry. Please indicate which Board Certification you possess in the text box below. If you do not possess either, please indicate N/A.

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