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#19-004256-0001
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a current license as a Nurse Practitioner or Nurse Midwife from the Maryland State Board of Nursing?  If yes, please submit a copy of your license or include the license number and expiration date on your application.

Yes No
2.

Please provide your license number and expiration date in the box below.

3.

Describe your experience working with infectious diseases, especially working with tuberculosis.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.

4.

Describe your experience in an outpatient setting.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.


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