Official SealDepartment of Budget and Management


#17-004603-0004
Supplemental Questionnaire

Last Name
First Name
1.
Do you have a current license to practice medicine in the State of Maryland?  Please submit a copy of your license with your application.
Yes No
2.

If yes, please provide your license type, license number and expiration date below.
3.

Describe your experience in the practice of medicine. 

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.
4.

Do you possess a Master's degree in Public Health from an accredited college or university?
Yes No

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