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#20-004284-0007
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 in the box below.
3.

Do you have experience providing nursing care to patients who are receiving either hemodialysis or peritoneal dialysis?
Yes No
4.

If you responded YES to the above question, please describe your work experience providing nursing care to patients who are receiving hemodialysis or peritoneal dialysis.  This experience should also be included in your application.

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