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#19-004301-0001
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 possesss a current certificate as a Nurse Practitioner, Psychiatric from the Maryland State Board of Nursing?

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

Are you willing to work and travel to all sites of Worcester County Health Department?

Yes No

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