Official SealDepartment of Budget and Management


#17-004246-0003
Supplemental Questionnaire

Last Name
First Name
1.
Do you possess a current LPN license from the Maryland Board of Nursing or one of the states in the Multi-State Licensure Compact Current Membership?
Yes No
2.

Please provide your license number and expiration date in the box below.
3.

This position will require working either the evening shift (3:30 p.m. to 12:00 a.m.) or the night shift (12 a.m. to 8:30 a.m.)  No day shift positions are available.

Are you willing to work either evening or night shift?
Evening
Night

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