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#20-004613-0001
Supplemental Questionnaire

Last Name
First Name

 

Please note that your answer on the supplemental questionnaire must correspond to the information that is provided on your resume to receive credit.


1

Do you possess a degree in medicine from an accredited college or university?

Yes No
2

Select you current medical licensure status.

Currently licensed to practice medicine by the Maryland Board of Physicians.
Currently licensed to practice medicine in a state other than Maryland.
Pending license to practice medicine by the Maryland Board of Physicians.
Pending licensure to practice medicine by a state other than Maryland.
Expired licensure to practice medicine.
Other
 

If you selected other, please indicate your reason below.

3
Do you posses a current Board Certification?
Yes No
 

Please provide your areas of speciality in the box below.  A copy of your board certification should also accompany your application.

4

Describe your experience in a public health setting.  Include any experience in public health policy, planning and testimony.

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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