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#18-002428-0006
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 certificate of eligibility to be licensed as a Registered Environmental Health Specialist from the Maryland Board of Environmental Health Specialists?  A copy of your certificate must be attached to your application. 
Yes No
2.

If you answered Yes to the above question, please provide your license number and expiration date in the space below.  If you do not possess a certificate of eligibility, please indicate N/A in the text box below.
3.

If you answered "No", do you possess a baccalaureate or master's degree from an accredited college or university that includes:

  1. at least 30 semester credit hours in the physical, biological or environmental sciences;
  2. at least one laboratory course in two of the following: chemistry, physics or biology, soil science, geographic information systems; and
  3. a course in mathematics.

You must provide documentation of these courses.  Please submit a copy of your transcripts with your application.  Transcripts may be unofficial. 

Yes No

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