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#21-000711-0003
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

Describe your experience with outreach or treatment of individuals with substance use disorders.

This experience must also be included on your application. Please be sure to include name of employer, job title, dates of employment and hours worked per week.

2

Describe your knowledge of and/or experience involving recovery housing. Indicate N/A in the text box if you do not possess this type of experience.

This experience must also be included on your application. Please be sure to include name of employer, job title, dates of employment and hours worked per week.


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