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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.***


Do you have a current Geriatric Nursing Assistant (GNA) License from the Maryland State Board of Nursing?

Yes No

If you possess a current GNA license from the Maryland State Board of Nursing, then please provide the GNA license number in the field below.  Type "NA" if you do not have a current GNA license. 


Do you have two years of experience providing direct care of patients in a medical setting?

Yes No

If yes, please describe your experience in detail including the name of the employer and dates of employment in which this work was performed.  If you do not possess this experience, please indicate N/A.

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