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#20-004247-0006
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 Licensed Practical Nurse (LPN) from the Maryland State Board of Nursing, or a license recognized by the Multi-State Compact agreement OR will you be sitting for the licensing exam within the next 90 days?

Yes No
2.

Please provide your license number and expiration date in the box below.

3.

This position will require working either the evening shift (4:00 p.m. to 12:30 a.m.) or the night shift (12 a.m. to 8:30 a.m.)  No day shift positions are available.

Are you willing to work either evening or night shift?

Yes No

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