Name/Address Verification Form

COMMISSION ON DIETETIC REGISTRATION
120 South Riverside Plaza, Suite 2000
Chicago, Illinois 60606-6995
312/899-0040, extension 4764 or 4781
For CRMS
Registration Eligibility Application Form
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Revised 4/13
MUST USE BLUE INK
Applicant for Dietitian Registration Examination
Applicant for Dietetic Technician Registration Examination
IMPORTANT ALL AREAS ON THIS FORM MUST BE COMPLETED TO ASSIST IN
PROMPT PROCESSING OF THE ELIGIBILITY APPLICATION. Failure to
NOTE:
complete and sign areas will result in processing delays.

Academy Member Number

____________
You must provide the number on a copy of your membership card, profile page or receipt.
Name/Address (Enter your name as it appears on your government-issued photo identification card.)
Last Name (Please Print)
First
Address
Middle Initial
Maiden
City
Previous
State
Zip
__________________________________________________________
Social Security Number (last four digits)
(_________)________________________
Home Phone Number
E-Mail Address
(_________)_______________________
Daytime - Work Phone Number
(Do not use an "edu" address)
(_________)________________________
Cell Phone Number
* * * THIS WHOLE FORM MUST BE COMPLETED IN BLUE INK ONLY * * *
After your Program Director submits the On-Line Registration Eligibility Application to the Commission on
Dietetic Registration (CDR):

the Commission will send confirmation of your registration eligibility status via e-mail, and

ACT, Inc. will e-mail the examination application and Candidate Handbook to the address noted above.
Please expect it within two to three weeks of CDR’s receipt of the Registration Eligibility Application.
Agreement to abide to the Academy/CDR Code of Ethics.
Upon passing the registration examination, “As a registered dietitian or dietetic technician, registered, I agree to abide by the
Code of Ethics for the Profession of Dietetics (http://www.eatright.org/HealthProfessionals/content.aspx?id=6868), and to hold
harmless the Commission on Dietetic Registration, other RDs and DTRs, and CDR employees for their activities in enforcing
them.”. Must Use Blue Ink.
____________________________________________________________________________________________________________
SIGNATURE OF REGISTRATION CANDIDATE
Denotes all information is accurate and the candidates acceptance of the Code of Ethics
___________________________________
Print or Type Program Director’s Name
___________________________________
Original Signature of Program Director
DATE (month/day/year)
____________________
4-Digit Program Code
PLEASE RETURN THIS FORM TO YOUR PROGRAM DIRECTOR AT THE CONCLUSION OF YOUR
PROGRAM ON OR BEFORE YOUR LAST DAY OF THE SUPERVISED PRACTICE PROGRAM.
CDR COPY
(This form must be returned to the Program Director for their submission to CDR)