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#17-004304-0003
Supplemental Questionnaire

Last Name
First Name

 

Please note that your answer on the supplemental questionnaire must correspond to the information that is provided on your resume to receive credit.


1

Do you possess a current license as a Physical Therapist from the Maryland State Board of Physical Therapy Examiners in accordance with Physical Therapy Article, Section 13-301 or as an Occupational Therapist from the Maryland State Board of Occupational Therapy Practice in accordance with Occupational Therapy Article, Section 10-301?

Yes No
2

If you answered Yes to the above question, please provide your license number and expiration date in the space below.  If you do not possess a certificate of eligibility, please indicate N/A in the text box below.

3

Do you possess a Master's degree or higher from an accredited college or university in Physical or Occupational Therapy?

Yes No
4

Please describe your supervisory experience.  Include employer name(s), job title(s), dates of employment, and titles of those you supervised.  If you do not possess this experience, enter N/A.


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