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#18-006810-0001
Supplemental Questionnaire

Last Name
First Name

 

Please note that your answer on the supplemental questionnaire must correspond to the information that is provided on your resume to receive credit.


1.

Are you currently licensed to practice medicine by the Maryland Board of Physicians?  (If Yes, please submit a copy of your license or license verification with your application.)

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.

3.

Please provide the date when you received your Board Certification.  Also provide your area of speciality.  Type "NA" in the field below, if this does not apply to you.

4.

Describe your medical practice experience. 

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. 

5.

Describe your experience in a chronic rehab facility.

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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