APPLICATION FOR LICENSED DIETITIAN/NUTRITIONIST

Transcription

1 APPLICATION FOR LICENSED DIETITIAN/NUTRITIONIST In accordance with Louisiana state law, you may not begin work until your license has been issued. Dear Applicant: Attached is an application packet for licensure as a Licensed Dietitian/Nutritionist. Included in the packet is a copy of LRS 37:3081 through 3093 and LRS 36:259 (U) and the Board s Rules and Regulations. Effective July, 1, 1988, no person shall use the titles dietitian, dietician, nutritionist, licensed dietitian, dietician or licensed nutritionist, or use the designation LD, or LN, or any other abbreviation or facsimile thereof unless he/she is licensed in accordance with the provisions of the Louisiana Dietetics/Nutrition Practice Act of Further, no person shall practice dietetics/nutrition or provide nutrition care services unless licensed or otherwise authorized to practice in accordance with the Dietetics/Nutrition Practice Act. If you cannot qualify in accordance with LRS 37:3086 (see enclosed law), you may qualify for a provisional license. Please contact the Board office at for more information concerning the provisional license. If you have ever held a license as a dietitian and/or nutritionist in another state, you must have that State Board complete and return a Verification of Licensure form. Annual License Renewal Forms are mailed in April. License renewals are due by June 30th of each year. Licensees must present proof of holding current CDR registration or proof of having completed 15 hours of continuing education to be submitted on Form E (Summary of Continuing Education). Please allow at least four (4) weeks for the processing of your license application. Louisiana Board of Examiners in Dietetics and Nutrition Highland Road, Suite B Baton Rouge, LA Telephone: (225) Fax: (225) Website:

2 INSTRUCTION SHEET 1. Read the Louisiana Dietetic/Nutrition Practice Act, (L.R.S. 37:3081 through 3093 and L.R.S. 36:259 (U)) before filling out this application. Please complete appropriate forms and follow the instructions provided. a. TYPE or PRINT IN INK LEGIBLY. Use additional pages as necessary throughout the form if sufficient space is not provided. b. List name on each of the forms. c. The Application Form MUST BE NOTARIZED. d. If not currently employed, check the box in Current Primary Employment Information. e. Academic Training Form (C), if required. Send only official transcripts of relevant college work. List maiden or other married names appearing on your transcript(s) if different from the applicant name. 2. FEE SCHEDULE: Licensed Dietitian/Nutritionist = $90.00 Includes $45.00 non-refundable application fee and $45.00 initial license fee. License Reciprocity = $ For applicants who hold, or who have held a dietetic/nutritionist license in another state. Includes $45.00 non-refundable application fee, $45.00 initial license fee and $25.00 reciprocity fee. RDs may apply as Licensed Dietitian/Nutritionist. Provisional Licensed Dietitian/Nutritionist = $95.00 Includes $45.00 non-refundable application fee and $50.00 initial license fee. Make Check/Money Order Payable to: LBEDN Mail completed notarized and signed application, material, and fee to: LOUISIANA BOARD OF EXAMINERS IN DIETETICS AND NUTRITION HIGHLAND ROAD, SUITE B BATON ROUGE, LA 70809

3 LOUISIANA BOARD OF EXAMINERS IN DIETETICS AND NUTRITION Highland Road, Suite B Baton Rouge, Louisiana Office: (225) Fax: (225) Website: admin@lbedn.org APPLICATION FOR LICENSED DIETITIAN/NUTRITIONIST 1. Applicant Name: 2. Name on transcript if different from #1 3. Date of Birth: 4. SS# (Required by LRS 37:23) 5. Home Address: (Street or Box Number) (City) (State) (Zip) 6. Parish of Residence: 7. Address: 8. Work Address: (Street or Box Number) (City) (State) (Zip) 9. Telephone: Home: ( ) Work: ( ) 10. Drivers License No: 11. Are you a Registered Dietitian? If YES, registration number: Submit copy of current CDR Identification card. 12. Have you ever possessed a professional license or certificate issued by another state(s)? List all states that you have previously held licensure: 13. Has any state rejected your application or revoked or suspended your professional license or certificate? 14. Have you ever been charged or convicted of any crime or unprofessional conduct? 15. To an extent that it impairs your functioning as a dietitian or nutritionist, have you ever used or are you currently using drugs, chemical substances (including controlled substances obtained either with or without a valid prescription), or intoxicating liquors? 16. Have you been a participant in an alcohol or drug treatment or rehabilitation program in which you were monitored or supervised relative to your use of drugs or alcohol? (If yes, submit Verification of License from each state) 17. Have you ever been adjudged mentally incompetent? LDN Application Rev. 5/2008 Continued

4 Act # 721 passed by the Louisiana Legislature in the 2003 Regular Session, mandates that State Licensing Boards ask the following questions. The information given is to remain confidential, and will be used to measure and track the supply of licensed professionals for statistical purposes by the Louisiana Department of Labor. 18. Employment in Dietetics/Nutrition: I am employed or self-employed in Dietetics/Nutrition: Part time (less than 36 hrs per week as defined by the Department of Labor). Full time (36-40 hrs per week as defined by the Department of Labor). I am not employed in the profession of Dietetics/Nutrition. 19. I am employed or self-employed in LA. I am employed in the profession out of LA. OPTIONAL: 20. I graduated with my degree in Dietetics/Nutrition in I moved to LA and obtained my license in I am: White Black/African American Hispanic Asian Other CURRENT PRIMARY EMPLOYMENT INFORMATION I am not currently employed in the field of dietetics/nutrition. 23. Employer: Address: (City) (State) (Zip) Telephone:( ) Address: Job Title: Dates of Employment: From to (Mo/Day/Yr) (Mo/Day/Yr) **PLEASE NOTE: Formal Job Description must be included as part of the Application. If you are not currently employed, please check applicable box above.** PLEASE READ CAREFULLY AND HAVE NOTARIZED NOTARIZED DECLARATION In making application to the Louisiana State Board of Examiners in Dietetics and Nutrition for the issuance of a license as a Licensed Dietitian/ Nutritionist, I have read and agree to abide by the R.S. 37:3081 through R.S. 36:259 (U). I also agree to complete application requirements and take examinations necessary for the processing of my application. I further understand that the application fee is nonrefundable and that the materials submitted for consideration become the property of the Board and are nonreturnable. I am aware of the schedule of fees and understand that additional fees must be paid to keep the license current. I agree to hold the Louisiana Board in Dietetics and Nutrition, its members, officers, agents and examiners free from any damage or claim for damage or complaint by reason of any action they or any one of them take in connection with this application or the failure of the Board to issue me a license and any other aspect of licensing. I hereby grant permission to the Board to seek any information or references it deems fit in securing my credentials pertinent to this application. I further agree that if issued a license, upon the revocation, suspension or cancellation of that license, I shall return the license certificate and license identification card to the Board. The information which I have provided in this application is truthful. I understand that providing false information of any kind may result in the voiding of this application, and my failing to granted a Licensed Dietitian/Nutritionist, or the revocation of my license. Sworn to and subscribed before me, undersigned Notary, this day of, 20. Applicant s Signature: Notary Public: ID# SEAL

5 Applicant Name: LICENSED DIETITIAN/NUTRITIONIST ELIGIBILITY ROUTE CHECK ONLY ONE ELIGIBILITY ROUTE FOR LICENSURE AND SUBMIT ALL THE FORMS INDICATED. A. Applicant is currently registered with Commission on Dietetic Registration (CDR). Submit this form, as well as the Application, and a photocopy of the current ID card issued by CDR. B. If Applicant is currently licensed by another state or has held a license in another state. Must submit this Form, as well as the Application, and Verification of Licensure for each state you hold or have held a license to practice Dietetics and/or Nutrition. C. Applicant holds a baccalaureate or higher degree with a major course of study in human nutrition, food/nutrition, dietetics or food system management and has completed all of the following requirements: 1. Planned experience approved by the American Dietetic Association or the Louisiana Board of Examiners in Dietetics and Nutrition (LBEDN). 2. The Board recognizes and accepts a passing score on the Registration Examination for Dietitians of the Commission on Dietetic Registration (CDR) as the Board s licensure examination. Submit this Form, as well as, the Application. Submit with official transcripts and verification of examination from CDR. FORM A 5/2008

6 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:

7 VERIFICATION OF LICENSURE Directions for State Board: Please complete and return this form to the Louisiana Board of Examiners in Dietetics and Nutrition at Highland Road, Ste. B, Baton Rouge, LA 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 uni versity with a major course of study in human nutrition, food and nutrition, die tetics 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): Title of Official: SEAL Board Name: Address: Date Completed: FORM D 5/2008