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#24-000312-0001
Supplemental Questionnaire

Last Name
First Name
1

Do you currently possess a license as a Licensed Clinical Professional Counselor (LCPC) from the Maryland Board of Professional Counselors and Therapists?
Yes No
2

If you answered "yes", please provide your license number and expiration date below.  You may also submit a copy of your license or license verification with your application.

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