North Carolina Board of Dietetics/Nutrition License Categories

North Carolina Board of Dietetics/Nutrition License Categories Category A: Applicant is currently registered with Commission on Dietetic Registration (CDR), OR applicant is provisionally licensed and is seeking to convert a Category B license to Category A. Category B: All Category B applicants: Please use separate application form ( Category B License Application/Provisional Licensed Dietitian/Nutritionist ) found on our website at www.ncbdn.org. Do not complete this application. Category C: Applicant holds a baccalaureate or higher degree from a regionally accredited college or university with a major course of study in human nutrition, nutrition education, foods and nutrition, dietetics, community nutrition or public health nutrition. The NCBDN will review application and notify applicant of eligibility status for Category C licensure, which includes subsequent completion of an A.N.D.-equivalent supervised practice program and examination for NC licensure only. Please contact the NCBDN office if interested in a Category C license and to seek additional forms. Category D: Applicant is currently licensed by another state and is seeking licensure by reciprocity. Only states with equivalent licensing requirements, as determined by the Board, will be considered. Registered Dietitians should apply under Category A. Category E: Applicant has received, from a regionally accredited college or university, a doctorate in human nutrition, nutrition education, foods and nutrition, public health nutrition, or an equivalent major course of study as approved by the Board, or has received a Doctor of Medicine. Category E applicants should contact the NCBDN office for additional forms. Registered Dietitians should apply under Category A. Application Checklist Verify Application Form is completed; any application that is not complete may be returned by US Mail to the applicant. Provide Copy of CDR registration (Category A only). Request for sealed transcript(s) to be sent directly to NCBDN office from educational institution (Categories C, D and E only) Complete Competency chart (Category C & E only). Competency chart must be requested directly from the Board office. Get Last Page of Application Notarized Include Payment (Check, Money Order, Visa, MasterCard or Discover) Mail application via standard postal service to: NCBDN, 140 Preston Executive Drive, Suite 205-C, Cary, NC 27513. Page 1 of 8

Applicant Instructions for Licensed Dietitian/Nutritionist (LDN) Please check the category you are applying for: Category A: Licensed Dietitian/Nutritionist = $175.00 Includes non-refundable application fee of $50.00 and Issuance Fee of $125.00. Please Note: If application is approved all fees are non-refundable. Please include a notarized photocopy of your current CDR Registration Identification Card or CDR licensure verification certificate. Please take your CDR card with you to the Notary to validate the copy. Provisional licensees (PLDNs) who have successfully completed the licensing examination within six months of the date that their provisional license became effective, need only pay the balance of the issuance fee, which equals $90.00, to convert from Category B licensure to Category A licensure. If a PLDN applies to upgrade from Category B to Category A, more than six months after their provisional license was issued (but before it expires) the fee due is $175.00. Category B (Provisional): Please use separate application form found on the NCBDN website at: www.ncbdn.org/forms/provisional_license_application. Category C: Non-RD pathway to Licensed Dietitian/Nutritionist = $475.00 1. Fee for approval by the Board of Academic Training Program - $75.00 This fee is not required if applicant has completed an ACEND Accredited Didactic or Coordinated Program in Dietetics 2. Fee for approval by the Board of Supervised Practice Training Program - $75.00 This fee is not required if applicant has completed an ACEND Accredited Supervised Practice program in Dietetics 3. Examination Fee - $150.00 NCBDN will forward Examination Application fee to the American College Testing program (ACT). This fee is required if a person is taking the examination for licensure purposes only. 4. Licensed Dietitian/Nutritionist = $175.00 Includes non-refundable application fee of $50.00 and Issuance Fee of $125.00. Please contact the NCBDN office if interested in Category C license. Please Note: If application is approved, all fees are non-refundable. Category D: Reciprocity = $250.00 Includes a non-refundable Application Fee of $50.00, Fee of $75.00 for approval of license requirements (academic training program, supervised practice training program, and examination) of another state as equivalent to those in North Carolina, and Issuance Fee of $125.00. You will need to have verification, along with a copy of application materials, sent to the NCBDN from the state you were licensed in. All Registered Dietitians apply under Category A. Please Note: If application is approved, all fees are non-refundable. Category E: Equivalent Education = $250.00 Includes a non-refundable Application Fee of $50.00, Issuance Fee of $125.00, and Fee of $75.00 for approval by the Board of Academic Training Program. (Fee is not required if applicant has completed an ACEND Accredited Didactic Program in Dietetics.) Please Note: If application is approved, all fees are non-refundable. All applicants MUST have the last page of this application notarized. Page 2 of 8

4. If paying by check or money order, please include it with this application packet, make payable to the North Carolina Board of Dietetics/Nutrition, and mail all completed/signed/notarized application materials to: North Carolina Board of Dietetics/Nutrition 140 Preston Executive Drive, Suite 205-C Cary, NC 27513 5. If paying by credit card complete the following: Visa MasterCard Discover Card in the Name of: Payment Amount: Billing Address (street address, apt #): City: State: Zip: Card Number: Tel # for billing address: Exp. Date: Security Code ( CVV - last 3 digits on back of card): Email of card holder: Signature of card holder: For any questions regarding the completion of this application, please contact us at: Telephone: (919) 388-1931 E-mail: info@ncbdn.org Website: www.ncbdn.org FAXED OR E-MAILED APPLICATIONS WILL NOT BE ACCEPTED. You will be notified via email or phone of approval or other assessment. Page 3 of 8

North Carolina Board of Dietetics/Nutrition Application for License Please read the Dietetics/Nutrition Practice Act (North Carolina General Statutes 90-350 through 90-369) and the Rules (21 NCAC 17.0101 through.0402), which can be viewed at www.ncbdn.org, under "Laws & Rules," before completing this application. Please print clearly and use additional pages if necessary. Mail completed application via standard postal mail service to NCBDN, 140 Preston Executive Drive, Suite 205-C, Cary, NC 27513. Faxed or emailed applications will not be accepted. * INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED AND MAY BE RETURNED TO APPLICANT * Personal Information: Date: (Mo/Day/Yr.) Social Security #*: Date of Birth: Gender: Male Female Applicant s Name: (First, Middle, Last) Credentials: Any other names previously used by Applicant: Applicant s Address (Number, Street, Apartment #)**: City: State: Zip Code: County: Email Address: Home Phone: ( ) Office Phone: ( ) Cell Phone: ( ) *Provision of your social security number is mandatory for child support enforcement purposes pursuant to NC G.S. 110-142, for potential disclosure to the US Department of Health and Human Services National Practitioner Databank, and to process your license. **Pursuant to 21 NCAC 17.0109(b), a change of address must be reported to the North Carolina Board of Dietetics/Nutrition in writing within 30 days. For Office Use Only Name: (First, Middle Last) Date License Issued License Number Type of License Approved By New NC license Reinstating licensee (past) Reinstating licensee (same year) Date certificate Packet Mailed: Page 4 of 8

Education: List all colleges and universities attended and all degrees/certificates earned: Granting Institution (name, city, state) Major Degree/Certificate Dates Attended (from Mo/Yr. to Mo/Yr.) Graduation Date (Mo/Yr.) Transcripts are not required for applicants presenting satisfactory evidence of current registration with the Commission on Dietetic Registration (CDR). All others (Category C, D, and E) must provide official sealed transcripts from all degree-granting colleges or universities. Pre-Professional Experience: Please indicate the type of experience you have completed. Check only one box. Dietetic Internship accredited by the Accreditdation Council for Education in Nutrition & Dietetics (ACEND) Coordinated Program in Dietetics accredited by ACEND Pre-Professional Practice Program approved by ACEND NCBDN Supervised Practice Program Other (specify): Name and Address of Supervised Practice Program Dates Attended (from Mo/Yr to Mo/Yr) Examination Information: If you have recently passed the examination for registration offered by CDR and have not received your registration card, but have received your RD number, you may visit the CDR website at www.cdrnet.org, verify your license, print out the on-screen certificate, and enclose a copy along with your completed application. Are you a Registered Dietitian with CDR? Yes No (You will not be considered for Category A licensure until you pass and obtain an RD number from CDR and provide proof thereof.) If yes, please provide your RD number: I am providing proof of my RD status by: Enclosing a notarized copy of my CDR card (last page of this application); OR Enclosing a copy of the online verification certificate from the CDR website (www.cdrnet.org) showing my RD number. You can obtain the online certificate by clicking on Online Credential Verification Search. The continuing educaiton requirements may be found in rule 21 NCAC 17.0109(g). Are you in compliance with the requirement for continuing education/professional development? Yes No If no, please explain: Page 5 of 8

Employment Information: List all work experience during the five year period preceding the filing of this application. Please include all positions, even if employment was outside of the field of dietetics/nutrition. If you have not been employed in any way during the last five years, please check this box: Employer Location of Employment ( full address & phone #) Job Title Supervisor Name Dates Employed *Attach additional positions on separate sheet if necessary. Primary Area of Practice: Community Nutrition Clinical Nutrition Consultation/Private Practice Food & Nutrition Management Education & Research Other: Supervision of Non-licensed Persons: Will you be supervising a Dietetic Technician or a student working to complete pre-professional experience as exempted under North Carolina General Statute 90-368? Yes No Legal Questions: It is your ethical responsibility to answer the following questions truthfully. Any false statement found by the NCBDN will be treated as a violation under North Carolina General Statute 90-363(a)(1). Should the NCBDN discover that you have violated N.C. General Statute 90-363, upon a hearing, the NCBDN reserves the right to refuse approval of your application. 1. Have you ever possessed a license to practice dietetics/nutrition issued by any state? Yes No If yes: State: License Number: Type: Date issued: Date Expired: IMPORTANT NOTE: If you have been licensed in North Carolina in the past and have a Lapsed License, please review our Lapsed License Procedure online at www.ncbdn.org under Laws & Rules, and contact the NCBDN for additional paperwork. 2. Have you ever been denied professional licensure, certification, or registration in any state for any reason? Yes No If yes, State: Date: 3. Has any license entitling you to practice in any state been revoked, suspended, or had probationary conditions imposed upon it? Yes No 4. Have you entered into an agreement of any kind with respect to a professional license (including a consent order), whether oral or written, in lieu of alternate legal action with any board, bureau, department, agency, or other body? Yes No Page 6 of 8

5. Have you been notified of any charges or complaints filed against you with any board, bureau, department, agency, or other body with respect to a professional license? Yes No 6. Do you have a physical or mental condition which affects your ability to perform the duties and responsibilities of a dietitian/nutritionist safely and competently? Yes No 7. Are you engaged in the current illegal use of controlled substances, other habit forming drugs, or other chemical substances to an extent that your ability to deliver nutrition services safely and competently is impaired? Yes No 8. Have you ever been criminally charged, convicted, indicted, found guilty, plead no contest, or entered a guilty plea of a violation of federal law, state law, or municipal ordinance (including DWI) other than a minor traffic violation? (Do not report any arrest, charge, or conviction that has been expunged.) Yes No If yes, explain the details of the charge(s) or conviction(s) and include a copy of any final judgment/order (attach additional sheets as needed). You may be contacted to provide additional information as necessary. 9. Have you ever been found to have committed an act or acts of malpractice, gross negligence, or incompetence in the practice of dietetics/nutrition? Yes No I hereby authorize the Commission on Dietetic Registration and its agents, all personal physicians, educational institutions, governmental agencies, my references, employers, and business and professional associates (past and present), to release to the North Carolina Board of Dietetics/Nutrition any information, files, or records requested by the Board in connection with the processing of this application. The information requested on this application is required by the North Carolina General Statutes and the North Carolina Administrative Code. The information will be placed on a computer system and will be used for the purposes of administering the functions of this office. All information provided, except medical records, social security number, and credit card number will be public record. Any applicant who knowingly makes a false statement on this application is guilty of a misdemeanor of the first degree under 90-363 of the North Carolina General Statutes. I hereby affirm that all the foregoing statements are true in every respect to the best of my knowledge. Signature of Applicant: Date: Note: It is a VIOLATION of the law, unless otherwise exempt, to practice dietetics/nutrition in North Carolina without a valid license. The North Carolina Board of Dietetics/Nutrition is an Equal Opportunity Employer and Service Provider. Page 7 of 8

Form A2: Evidence of Current Status of Registration with the Commission on Dietetic Registration If you ARE currently registered with the Commission of Dietetic Registration (CDR) and are seeking to become a Licensed Dietitian/Nutritionist under Eligibility Category A, you must provide evidence of current registration as a Registered Dietitian by the CDR utilizing one of these two methods: 1. Photocopy your current registration identification card issued by CDR in the area allotted on this page (NOT the membership card issued by A.N.D.) and complete this form with a Notary Public; OR 2. If you have not received your identification card issued by CDR, but have obtained your RD number from CDR, you may verify your RD status online at www.cdrnet.org, print out your online verification certificate and include it with this application instead of photocopying your card here. You must have the bottom of this form NOTARIZED either way. Please note: You may not apply for a new Category A license or Category B conversion until you have been issued your RD number, verified it here by one of the above two methods, have signed in the shaded area below, and had this page notarized. Place your current CDR identification card here, then photocopy, sign in shaded area, and have this page notarized; OR If you do not have your CDR card yet, but know the number, please enter it on the line below and attach a copy of your online verification certificate obtained online at www.cdrnet.org, sign in shaded area, and have this form notarized. I, attest that, as the copy of my identification card or copy of my registration certificate indicates, I am a Registered Dietitian with the Commission on Dietetic Registration. Signature of Applicant: Date: OR If you ARE NOT currently registered with the Commission of Dietetic Registration (CDR) and are seeking to become a Licensed Dietitian/Nutritionist under Eligibility Category C, D, or E, you must verify that you are not registered as a Registered Dietitian by the CDR. I,, verify that I am not a Registered Dietitian with the Commission on Dietetic Registration. Therefore, I am seeking: Category C licensure Category D licensure Category E licensure Signature of Applicant: Date: Must be completed by a Notary Public: County, State of Signed and sworn to before me this day by (Applicant Name) Date: Official Signature of Notary: Notary's printed name: My commission expires: Notary Seal Page 8 of 8 Mail Applications to: NCBDN, 140 Preston Executive Drive, Suite 205-C, Cary, NC 27513