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#20-005482-0012
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

Describe in the box below your direct care experience providing case
management services to emotionally or socially maladjusted, delinquent,
victimized, or exceptional juveniles in a community or residential setting.
Provide the dates of employment and the name of the employer where you
performed such duties. If you do not possess this experience, enter N/A.

2

Describe in the box below your experience exercising supervisory or
managerial responsibility for line and or management staff providing
services to juveniles. Include employer name(s), job title(s), dates of
employment, and titles of those you supervised/managed and explain your
supervisor/managerial duties. If you do not possess this experience, enter
N/A.


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