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#18-000612-0004
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.

Are you licensed as a Psychologist from the Maryland Board of Examiners of Psychologists?  (If you respond Yes, please upload a copy with your application)

Yes No
2.

Please describe your experience working with juvenile offender populations or adolescent population in a juvenile facility or juvenile services community program for at-risk youth. Provide the dates of employment and the name of the employer where you performed this responsibility, and hours per week worked.

 


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