Free 47586.FH11 - Indiana

APPLICATION FOR INDIANA DIETITIAN CERTIFICATION
State Form 47586 (R2 / 1-06) Approved by the State Board of Accounts, 2006

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INDIANA DIETITIANS CERTIFICATION BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2043 E-mail: [email protected]

NOTICE: Applications will not be reviewed until all required documents are received by the Board.

* Mandatory disclosure of U.S. Social Security number

Pursuant to Section 7 of the Privacy Act of 1974, you are hereby given notice that disclosure of your U.S. Social Security number on this application is mandatory for the purpose of complying with IC 25-1-5-8 and IC 4-1-8-1 which provide that the Indiana Department of Revenue may obtain Social Security numbers from the Professional Licensing Agency for tax enforcement purposes.

APPLICANT
Attach one (1) passport type quality photographs of yourself taken within the last eight weeks.

Date of receipt (month, day, year) Receipt number Amount paid Certification number Date of certificate issuance (month, day, year)

DO NOT WRITE ABOVE THIS LINE APPLICANT INFORMATION
Last name of applicant First name Middle name Maiden name

Address (number and street or rural route number) City Social Security number * T elephone number (daytime) State Date of birth (month, day, year) RD Registration number ** ZIP code Place of birth (city and state) E-mail address

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** Attach a copy of your registration card as provided by the Commission on Dietetic Registration. If you do not have, refer to E(2) of the instruction sheet. EDUCATION List all colleges and universities attended. Attach official or notarized transcript(s) from all degree granting colleges or universities. CERTIFICATE / DEGREE GRANTING INSTITUTION CITY STATE MAJOR CERTIFICATE / DEGREE GRADUATION DATE (month, year) DATES ATTENDED From (mo., yr.) To (mo., yr.)

PRE-PROFESSIONAL EXPERIENCE
Indicate the type of experience you have completed (check only one box)

Dietetic internship accredited by the Commission on Dietetic Registration (CDR) Coordinated program in Dietetics accredited by CDR Other (specify) ___________________________________________ Pre-Professional Practice programs approved by CDR _______________________________________________________ Indicate place(s) and dates of experience checked above. DATES ATTENDED NAME OF PLACE(S) AND ADDRESS From To (mo., yr.) (mo., yr.)

EXAMINATION INFORMATION
Are you a Registered Dietitian (RD) with the Commission on Dietetic Registration (CDR)?

Yes Yes

No No

Made application

If No, complete the intern / experience form.

Have you passed an examination offered by the Commission on Dietetic Registration (CDR) for licensure, certification or registration in another state?

EMPLOYMENT INFORMATION List all professional work experience, full or part time, during the five year period immediately preceding the filing of this application. NAME AND LOCATION OF FACILITY JOB TITLE AREA OF PRACTICE DATES From (mo., yr.) To (mo., yr.)

APPLICATION AFFIRMATION List all states, including Indiana, in which you have been licensed to practice any regulated health occupation. TYPE OF LICENSE STATE NUMBER DATE ISSUED

CURRENT STATUS

If your answer is "Yes" to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including location, date and disposition. If malpractice, provide name of plaintiff. Falsification of any of the following is grounds for permanent revocation of a license or certificate issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice dietetics or any other regulated health occupation in any state (including Indiana) or country? 3. Are you now, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, pled guilty or nolo contendere to: A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction. B. Any offense, misdemeanor or felony in any state? (except for minor violations of traffic laws resulting in fines) 5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had membership or privileges revoked, suspended or subjected to any restriction, probation or other type of discipline or limitations? 6. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 7. Have you ever had a malpractice judgement against you or settled any malpractice action? AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association or institution to release to the Indiana Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned, requested by the Agency, or any of its authorized representatives in connection with processing my application for dietitian certification. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Indiana Professional Licensing Agency to disclose to the aforementioned organizations, persons and institutions any information which is material to my application, and I hereby specifically release the Agency and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm under penalties of perjury that the statements made in this application are true, completed and accurate to the best of my knowledge.
Signature of applicant Date signed (month, day, year)

Yes Yes Yes

No No No

Yes Yes Yes Yes Yes

No No No No No