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#19-004266-0002
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.

Candidates for positions in this classification must possess a current license as an Occupational Therapist from the Maryland State Board of Occupational Therapy Practice.

Do you currently possess a license as an Occupational Therapist in Maryland?  If yes, please attach a copy to your application.

Yes No
2.

If you answered Yes to question 1, please provide your license number and expiration date in the box below.  If No, please enter N/A in the box below.


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