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#17-004266-0002
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.

Candidates for positions in this classification must possess a current license as an Occupational Therapist from the Maryland State Board of Occupational Therapy Practice.

Do you currently possess a license as an Occupational Therapist in Maryland?  If yes, please attach a copy to your application.

Yes No
2.

If you answered Yes to question 1, please provide your license number and expiration date in the box below.  If No, please enter N/A in the box below.

3.

Describe your experience as an Occupational Therapist.

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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