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#17-002428-0011
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 certificate of eligibility to be licensed as a Registered Environmental Health Specialist from the Maryland Board of Environmental Health Specialists?  A copy of your certificate must be attached to 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.

Describe your experience in environmental health.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.


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