Official SealDepartment of Budget and Management

Supplemental Questionnaire

Last Name
First Name

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

Yes No

Please provide your license number and expiration date in the box below.


Describe your work experience assisting in the care, treatment, habilitation or rehabilitation of mentally or physically ill patients, aged or developmentally disabled 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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