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#12-000465-002
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 currently possess a doctorate degree in psychology, or will you receive one within six months?

Yes No
2

By checking this box, I hereby certify that I read and fully understand the items listed below, and that I am willing to conform to these terms and conditions of employment as a Department of Juvenile Services employee.

In accordance with the Annotated Code of Maryland, Health Occupations, 18-301 (b4), the Psychology Associate, Doctorate is required at the time of hire to apply jointly with the supervising Psychologist to the State Board of Examiners of Psychologists for an exemption from licensure. The exemption must be received within six months of submitting the application.

The employee must become licensed as a psychologist by the Maryland Board of Examiners of Psychologists within three years of appointment to a position in the Psychology Associate, Doctorate classification.


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