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#17-004287-0005
Supplemental Questionnaire

Last Name
First Name

 

Please ensure your responses to the following supplemental questions are documented in the spaces provided for each question.  This includes dates of employment and employer information. Otherwise, you will not receive credit for the questions.


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.  Please include dates of employment and hours worked per week.
4.

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

5.

Describe your supervisory, teaching or administrative experience in nursing, including dates and hours worked. If none, enter "N/A".


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