Free 47587.FH11 - Indiana

AFFIDAVIT OF EXPERIENCE DIETITIAN INTERN TRAINING PROGRAM
State Form 47587 (R / 2-06)

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INSTRUCTIONS:

1. Affidavit to be completed by the CERTIFIED or REGISTERED SUPERVISING DIETITIAN of the Dietitian Interns training period. 2. Give EXACT dates and number of hours employed. 3. Return form to: INDIANA DIETITIAN CERTIFICATION BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204

IMPORTANT NOTICE TO PERSONS WHO HAVE AFFIDAVITS EXECUTED OUTSIDE OF INDIANA Each internship completed outside of this state must be accompanied by certification from the Board of Dietetics in the state where served.
State in which affidavit executed County in which affidavit executed Date affidavit executed (month, day, year)

CERTIFIED / REGISTERED DIETITIAN
Name of certified / registered dietitian (first, middle, last) Name of employer Address of employer (number and street, city, state, and ZIP code) State certified in Certificate number

DIETITIAN INTERN APPLICANT
Name of intern (first, middle, last) Address of intern (number and street, city, state, and ZIP code) Certificate number

WEEK(s) EMPLOYED (ending on) Month Day Year

NUMBER OF HOURS EMPLOYED PER WEEK

WEEK(s) EMPLOYED (ending on) Month Day Year

NUMBER OF HOURS EMPLOYED PER WEEK

TOTAL number of weeks employed

TOTAL number of hours employed

TOTAL length of employment (month, day, year) From To

The above employment information was taken from payroll or other records which are kept at (name of employer):

AFFIDAVIT On this day, I certify: 1. That I am a certified, registered or licensed dietitian holding the certification number listed above in the state declared: and 2. That the dietitian intern, named and located at the address above, was in my employ and under my supervision for the total number of hours and for the length of employment indicated. I solemnly swear, or affirm that the statements given above are true and correct to the best of my knowledge.
Signature of certified / registered dietitian Date signed (month, day, year)