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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. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**



Do you have a current Certified Nursing Assistant license in Maryland?

Yes No

If you currently possess a current Certified Nursing Assistant license, then type your CNA license number in the field below.  Please note that you are required to upload a copy of your license with your application.

If you do not have a CNA license, then type "N/A" in the field below.


Describe your work assisting in the care, treatment, habilitation or rehabilitation of developmentally disabled, mentally ill, physically ill or aged individuals in treatment facilities or community based programs.  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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