Official SealDepartment of Budget and Management


#12-001992-001
Supplemental Questionnaire

Last Name
First Name
1.

Do you currently possess a license as a Certified Social Worker (LCSW) or Certified Social Worker, Clinical (LCSW-C) by the Maryland State Board of Social Work Examiners?

Yes No
2.

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.


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