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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.**



Please explain your experience as a Registered Nurse in a supervisory, administrative or consultative capacity. Please include the employer(s) names, dates of employment, job duties and hours worked per week. If you do not have this experience, please write N/A.


Please describe your experience working as a Registered Nurse in a Psychiatric setting.  Include dates and hours worked per week.  If you do not possess experience in this area, put N/A in the box below.


Do you possess a current license as a Registered Nurse from the Maryland State Board of Nursing, or a license recognized by the Multi-State Compact agreement?

Yes No

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


This position will require you to work weekends and holidays.  Please indicate that you agree to and understand this job requirement.

Yes No

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