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#22-004216-0106
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.

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
2.

Please provide your license number and expiration date OR the date you will be sitting for the exam. Not providing this information may result in disqualification.

3.

Do you possess a Bachelor's degree from an accredited college or university?

Yes No
4.

What is the major field of study for your bachelor's degree? If you answered "No" to the previous question, please enter N/A in the box.

5.

Bilingual applicants are encouraged to apply.

Are you able to speak, read and write in both English and another language?

Yes No
6.

If yes, please note the languages of which you are bilingual.  Please also indicate if you are able to read, write and speak fluently in the languages.

7.

Describe your experience working with disabled and/or elderly populations.

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.

8.

Describe in 1-3 paragraphs, your experience with home visiting.

Do not copy and paste from your resume. 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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