ACADEMY OF NUTRITION AND DIETETICS
COMMISSION ON DIETETIC REGISTRATION
120 South Riverside Plaza, Suite 2000
Chicago, Illinois 60606-6995
800/877-1600, Ext 5500 (CDR), Ext 5000 (Academy)
Name/Address Change Form
All name changes MUST be submitted with legal documentation via mail to the Academy or CDR.
Documentation must include the original legal document (marriage license/certificate, divorce decree or court
order) showing the name change. A notarized copy of the original document will also be accepted.
ALL FIELDS REQUIRED
- PLEASE PRINT
This completed form must accompany all name/address changes.
Academy Membership/Registration Identification Number:_____________________
Current Database Name/Address:
___________________________________________________________________________________________________
Middle Name
Last Name (Please Print)
First
___________________________________________________________________________________________________
Address
City
State
Zip
__________________________________________________________________
__________________________________________________________________
Email Address
Primary Telephone Number
NEW DATABASE INFORMATION:
_________________________________________________________________________________________________
Middle Name
Last Name (Please Print)
First
___________________________________________________________________________________________________
Zip Code
Address
City
State
__________________________________________________________________
Email Address
_______________________________________________
_______________________________________________
Previous Name(s)
Maiden Name
Date of Birth (MM/DD/YYYY):_____________________________________________ REQUIRED
Mother's Maiden Name:____________________________________________________ REQUIRED
__________________________________________________________________
___________________________________________________
Primary Telephone Number
Type (Home, Office, Cell)
___________________________________________________
__________________________________________________________________
Additional Telephone Number
Type (Home, Office, Cell)
__________________________________________
__________________________________________________________________
SIGNATURE
DATE
Do you wish for your documentation to be returned to you? □ Yes
□ No
Documentation will be returned by First-Class Mail within four weeks of processing.
The Academy/CDR is not responsible for any lost or misdirected return mail.
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