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#21-004606-0009
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

Are you currently licensed to practice medicine by the Maryland Board of Physicians?  (If Yes, please submit a copy of your license or license verification with your application.)

Yes No
2

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.

3

This position requires that you possess a Board Certification.  Please indicate the field in which you have your Board Certification.


4

If you answered yes, please upload a copy of your current license or certification with your application.


5

Do you possess a current Maryland Controlled Dangerous Substance Registration?

Yes No
6

Do you possess a Federal DEA license?

Yes No
7

Do you possess a practitioner waiver to administer, dispense and prescribe buprenorphine? If yes, please upload waiver to the application.

Yes No
8

Describe your experience in addiction medicine.

This experience must also be included on your application (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 indicate N/A.


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