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#18-004606-0008
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 possess a degree in medicine from an accredited college or university?

Yes No
2.

Are you licensed by the Maryland Board of Physicians to practice medicine under Maryland State Law?  If so, please attach copy of license to application.

Yes No
3.

Do you currently possess certification by an American Medical Association Specialty Board in Pediatrics?  If so, please attach copy of certification to application.

Yes No
4.

Please describe your experience, including training and skills, working with sexually or physically abused children.  This experience must also be reflected in your application.  If you do not possess this type of experience, please indicate N/A  in the text box below.


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