Name/Address Change Form for Registration Eligibility

Name/Address Change Form for Registration Eligibility
Note: Name change requests MUST include either an original marriage license, divorce decree or court order or a
notarized copy. All fields of the application must be completed in order to update your record.
________________________________________
Academy Membership Number (If Applicable)
PREVIOUS INFORMATION (The information that was submitted to your to CDR when you became registration eligible)
_________________________________________________________________________________________________________
Last Name (Please Print)
First Name
Middle Name/Initial
Maiden Name
_________________________________________________________________________________________________________
Address
_________________________________________________________________________________________________________
City
State
Zip
Country
_________________________________________________________________________________________________________
Email Address
Date of Birth (MM/DD/YYYY)
Mother's Maiden Name
NEW INFORMATION (Enter your name as it appears on your current, updated government-issued photo identification
card.)
_________________________________________________________________________________________________________
Last Name
First Name
Middle Name/Initial
_________________________________________________________________________________________________________
Address
_________________________________________________________________________________________________________
City
State
Zip
Country
____________________________________
Email Address
__________________________________________________________________________________________________________
Primary Phone (Circle Type: Cell/Home/Office)
Alternate Phone (Circle Type: Cell/Home/Office)
______________________________________________________________________________________________________________________
CANDIDATE SIGNATURE
DATE
Mail completed form to:
Peggy Anderson or Rebecca Beavers
Commission on Dietetic Registration
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606