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#21-004285-0001
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

Please select which vacancy you are applying for:

Part Time - 11:00 pm - 7:00 am
Full Time - 2:40 pm - 11:10 pm
I am interested in either position.
2

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
3

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

4

Please describe your experience working as a Registered Nurse in a Psychiatric setting.  Include dates and hours worked per week.  If you do not possess experience in this area, put N/A in the box below.


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