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#17-004703-0001
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

Are you licensed as a Psychologist from the Maryland Board of Examiners of Psychologists?  (If you respond Yes, please upload a copy with your application)

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

When did you receive your license as a Psychologist?  Include month and year in the space below (i.e., May 2010).

4

Describe your experience rendering psychological services or engaged in psychological research after receipt of your license as a psychologist.  Do not include experience prior to receiving your license. 

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.


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