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#17-004291-0005
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. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 
1

Which shift are you willing to work:
Evening Shift (3 p.m. to 11:30 p.m)
Night Shift (11:15 p.m. to 7:15 a.m.)
2

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
3

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

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