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#21-004608-0002
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.

Are you currently licensed to practice medicine by the Maryland Board of Physicians?  (If Yes, please submit a copy of your license or license verification with your application.)

Yes No
 

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.

3.

Do you possess a Master's degree in Public Health from an accredited college or university?

Yes No
4.

Describe your experience as a licensed physician working in the field of public health.

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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