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#17-004146-0002
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 LPN license from the Maryland Board of Nursing or one of the states in the Multi-State Licensure Compact Current Membership?
Yes No
2.

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

3.

Describe your experience providing direct patient care in a psychiatric setting. 

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.


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