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#18-004007-0001
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. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1.

Do you have a high school diploma or high school equivalency certificate (GED)? (This information must be reflected in the education section of the application)

Yes No
2.

Describe your work experience assisting in the care, custody and guidance of court-ordered developmentally disabled individuals in treatment facilities or community based programs.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.


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