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#20-005479-0006
Supplemental Questionnaire

Last Name
First Name

 

Please note that your answer on the supplemental questionnaire must correspond to the information that is provided on your resume to receive credit.


1

Are you licensed as a Psychologist from the Maryland Board of Examiners of Psychologists?  (If you respond Yes, please upload a copy with your application)

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.

3

Do you possess a Doctorate in Psychology?

Yes No
4

What year did you receive your doctorate degree?

5

Describe your experience rendering psychological services.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

6

Describe your post-doctorate clinical experience rendering psychological services.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

7

Describe your supervisory experience in a setting where psychological services were rendered.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.


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