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#21-004246-0003
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 LPN license from the Maryland Board of Nursing or one of the states in the Multi-State Licensure Compact Current Membership?
Yes No
2.

Please provide your license number and expiration date in the box below.
3.

The candidate selected for this position must be willing to work evenings, weekends and holidays. Are you willing to work evenings, weekends and holidays?
Yes No

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