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#20-000552-0001
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. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1

Do you possess 60 credit hours from an accredited college or university including 12 credit hours in chemistry or biology? If YES, please attach transcript(s) to application.

Yes No
2

Describe your four (4) years work experience as a Laboratory Assistant or Technician performing public health, forensic or medical laboratory tests.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.


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