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#21-001030-0001
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a current license from the Maryland State Board of Examiners for Speech-Language Pathologists or the Maryland State Board of Examiners for Audiologists? 

Yes No
2.

If you answered yes, please attach a copy of your license to your application.  Also, provide the license number and expiration date below.

3.

Do you possess a Certificate of Clinical Competence in Speech Pathology or Audiology?  If yes, please attach a copy of your certificate to your application.

Yes No

 

Failure to submit the required documentation may result in disqualification.


4

Describe your experience as a Speech-Language Pathologist or Audiologist.

Please include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the space below.

5

Describe your school health experience. 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 put N/A in the box below.

 


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