:: Initial Applications ::

Instructions Step 1 / 10

Note:Application may take up to 30 days to process. If you have questions regarding the status of our application please email [email protected]

Citizenship Step 2 / 10

Are you a United States citizen or legally present in the U.S. with appropriate documentation from the federal government?

Yes

A copy of your current drivers license or picture l.D. Must also accompany this application

Demographics Step 3 / 10

Last Name

First Name

Middle Name

Social Security No

Date Of Birth

Gender

Male

Female

Mailing Address

Address 1

Address 2

City

State

Zip Code

Telephone No: Home/Cell

Work Phone

Email Address

Current Employment Step 5 / 10

List your current or most recent place of employment. If necessary, the person(s) listed as supervisor(s) will be sent a form from the Board to certify your experience.

Place of Employment:

Address 1

Address 2

Supervisor

Telephone No

Dates of Employment From Date

Dates of Employment To Date

Employment Type

Full Time

Part Time

Job Title

Academic Training Step 6 / 10

List all colleges and universities attended

Verification of Completion of College or University Program

Pre-Professional Experience Step 7 / 10

Indicate below the type of pre-professional experience in dietetics and indicate where and when completed.

Internship

Coordinated undergraduate program in dietetics

AP4 (Approved Practice Program)

Name of Facility, Agency, or Institute

Address1

Address2

City

State

Zip Code

Inclusive Dates of Experience From Date

Inclusive Dates of Experience To Date

Standards Of Professional Responsibility Step 8 / 10

I have read and agree to abide by the Dietetic/Nutrition Practice Act of 1989, the Rules and Regulations of the Alabama Board of Examiners for Dietetic/Nutrition Practice and, the Code of Ethics for the Profession of Dietetics as adopted by the American Dietetic Association. I further understand that the fee submitted with this application is nonrefundable and that the materials submitted for consideration become the property of the Board and are non-returnable. I am aware of the schedule of fees (282-X-8-.01) and understand that additional fees must be paid to keep the license current.

I agree to hold the Alabama Board of Examiners for Dietetic/Nutrition Practice, its members, officers, agents, and examiners free from any damage or claim for damage or complaint by reason of any action they or any one of them take in connection with this application, the failure of the Board to issue me a license and any other aspect of licensing. I hereby grant permission to the Board to seek any information or references it deems fit in securing my credentials pertinent to this application.

I further agree that if issued a license, upon the revocation, suspension or cancellation of the license, I shall return the license certificate and license identification card to the Board.

The information, which I have provided in this application is truthful. I understand that providing false information of any kind may result in the voiding of this application, and my failing to be granted a license or limited license or the revocation of my license.

Date

Signature of Applicant

Preview Step 9 / 10

Affirm And Submit Step 10 / 10

Fee

Licensing Fee

Convenience Fee

Total Amount

Payment Type

Person`s Name on card

Card Type

Card Number

Expiration Date(MM/YY)

Security Code

Name of College/University/Institution

Location

From Date

To Date

Type of Degree Granted

Major Field

TEMPORARY APPLICATION FOR LICENSURE