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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.**



Do you possess a current license as a graduate (LGSW/LMSW) or certified (LCSW) social worker from the Maryland Board of Social Work Examiners OR will you be sitting for the exam within the next 90 days?

Yes No

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.

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