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#22-004256-0001
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

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 within a clinical setting.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

4

Describe your experience working with public health programs and services.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

5

Describe your administrative work which includes grant writing and grant expenditures.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.


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