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#18-002429-0003
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 current license as a Registered Environmental Health Specialist from the Maryland Board of Environmental Health Specialists?  Please upload a copy of your license to the 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.


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