Directions for Applicant: Complete front portion of form and forward

Directions for Applicant:
Complete front portion of form and forward one to each state where
you hold or have held a license, to practice Dietetics and/or Nutrition.
Your application for a Louisiana license will not be processed until the
forms are returned to our office.
_____________________________________
State Board
I am applying for a license to practice dietetics/nutrition in Louisiana based on endorsement. I
was granted license number___________ on____________________ by the State of
__________________________.
The Louisiana Board of Examiners in Dietetics and Nutrition request that I submit verification
that my license in the State of ___________________________ is in good standing.
You are hereby authorized to release any information in your files, favorable or otherwise, directly to the Louisiana Board of Examiners in Dietetics and Nutrition. Your prompt attention will
be appreciated.
Signature: ________________________________________________
Print Name: _______________________________________________
Address:__________________________________________________
City, State, Zip:_____________________________________________
Date:_____________________________________________________
VERIFICATION OF LICENSURE
Directions for State Board: Please complete and return this form to:
Louisiana Board of Examiners in Dietetics and Nutrition
Towne Park Centre
37283 Swamp Road, Suite 3B
Prairieville, LA 70769
Name of Licensee: __________________________________________________________
License Type: ______________________________________________________________
License #: _______________________ Date Issued: ______________________________
Please list the requirements that were met by the Licensee in order to obtain the license.
______ Current Registration with the Commission on Dietetic Registration (CDR)
______ Receipt of a baccalaureate or higher degree from an accredited college or university with a major course of study in human nutrition, food and nutrition, dietetics or food systems management.
______ Completion of a program of experience of not less than nine hundred
supervision hours.
______ Satisfactory completion of Examinations:
______ CDR
______ State Prepared
Is the License current?
____ Yes
____ No
Critical Information?
____ Yes ____ No
If yes, please explain________________________________________________________
__________________________________________________________________________
Other comments: __________________________________________________________
__________________________________________________________________________
Signature:_______________________________________
Name (printed): __________________________________
SEAL
Title of Official:___________________________________
Board Name: ____________________________________
Address:________________________________________
________________________________________
Date Completed:_________________________________