Department of Budget and Management

**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.**

Do you possess a current license as a Nurse Practitioner or Nurse Midwife from the Maryland State Board of Nursing?  If yes, please submit a copy of your license or include the license number and expiration date on your application.

If you responded YES to the above question, please provide your license number and expiration date in the text box below.

Describe your experience as a Nurse Practitioner or a Nurse Midwife.

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.

Describe your professional experience as a Nurse Practitioner, including providing care for both males and females. Such care should include comprehensive women's health services, as well as Sexually Transmitted Disease (STD) diagnosis and treatment.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.

Describe your local public health experience in primary and preventative care.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.

Describe your experience providing and/or conducting consultations, patient education, guidance, and emergency preparedness activities.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.