Official SealDepartment of Budget and Management


#24-009283-0001
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 licensed by the Maryland Board of Physicians to practice medicine under Maryland State Law?  If so, please attach copy of license to application.
Yes No
3

If you answer no to the question above, do you possess a license to practice medicine in another state?  

If yes, please list the state and license number.
4

Do you currently possess a certification by an American Medical Association Specialty Board in Psychiatry?  (If Yes, please submit a copy of your certification with your application.)
Yes No
5

Do you possess Board Certification in Forensic Psychiatry?
Yes No
6

Do you possess a current Maryland Controlled Dangerous Substance Registration?
Yes No
7

Describe your experience providing clinical psychiatry services and substantial direct patient care, at multiple levels of care.

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.

Powered by JobAps