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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.**



Are you licensed as a dental assistant through the Maryland Board of Dental Examiners?  If yes, please submit a copy of your license with your application.

Yes No

Are you currently listed as a dental assistant qualified to place and expose x-rays by the Maryland Board of Dental Examiners?  A copy of your certification must accompany your application.

Yes No

Describe your experience assisting a Dentist in the performance of dental 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.  If you do not possess experience in this area, put N/A in the box below.

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