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#17-004219-0008
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

Do you have a Bachelor's degree in Nursing from an accredited college or university?

Yes No
4

Describe your experience as a community health nurse. 

Include name of employer, job title, dates employed, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the box below.

5

Describe your experience in an administrative, supervisory, consultative, or teaching capacity as a registered nurse. 

Include name of employer, job title, dates employed, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the box below.


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