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Supplemental Questionnaire

Last Name
First Name


Please note that your answer on the supplemental questionnaire must correspond to the information that is provided on your resume to receive credit.


Do you possess a current license as a Physical Therapist from the Maryland State Board of Physical Therapy Examiners in accordance with Physical Therapy Article, Section 13-301 or as an Occupational Therapist from the Maryland State Board of Occupational Therapy Practice in accordance with Occupational Therapy Article, Section 10-301?

Yes No

If you answered Yes to the above question, please provide your license number and expiration date in the space below.  If you do not possess a certificate of eligibility, please indicate N/A in the text box below.


Do you possess a Master's degree or higher from an accredited college or university in Physical or Occupational Therapy?

Yes No

Please describe your supervisory experience.  Include employer name(s), job title(s), dates of employment, and titles of those you supervised.  If you do not possess this experience, enter N/A.

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