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#17-004285-0003
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.***


1.

Do you possess a current license as a Registered Nurse from the Maryland State Board of Nursing, or a license recognized by the Multi-State Compact agreement?

Yes No
2.

Please provide your license number and expiration date in the box below.

3.

Describe your experience as a Registered Nurse in a psychiatric setting, including dates and hours worked.

4.

 Are you able and willing to work the 2nd shift from 2:40 p.m. - 11:10 pm

Yes No

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