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#19-009009-0005
Supplemental Questionnaire

Last Name
First Name
1.

Please indicate your American Sign Language skill level:
Polite (able to greet and exchange pleasantries; indicate or understand an emergency)
Literate (understands a conversation and can respond)
Fluent (is your native language or can converse in the language as if it was your native language.)
Do not speak sign language.
2.

Do you hold a current license from the Maryland State Board of Examiners for Speech-Language Pathologists? If yes, please attach a copy with your application.
Yes No

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