Official SealDepartment of Budget and Management


#12-004246-001
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a current license as a Licensed Practical Nurse (LPN) from the Maryland State Board of Nursing, or a license recognized by the Multi-State Compact agreement OR will you be sitting for the licensing exam within the next 90 days?
Yes No
2.

Please provide your license number, expiration date and state (if it is a compact state) OR the date you will be sitting for the exam. Not providing this information may result in disqualification.

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