Form 08-4400 - Application For Dietitian License (Page 2 of 3) in pdf

Form 08-4400 - Application For Dietitian License Page 2

Professional Fitness (AS 08.38.040)

All “yes” answers to the following questions must be explained in detail on a separate sheet of paper. Please

attach official documents as appropriate.

YES

1. Have you ever engaged in deceit, fraud, or intentional misrepresentation in the course of

providing professional services or engaging in professional activities? ................................

2. Have you ever been convicted of a felony? .........................................................................

3. Have you ever had your professional license suspended, revoked, reprimanded, or

otherwise acted upon?.........................................................................................................

4. Have you ever engaged in lewd or immoral conduct in connection with the delivery of

professional services? .........................................................................................................

5. Are you now or have you, within the last five years, experienced, been diagnosed with, or

been treated for emotional or mental illness, drug addiction, or alcoholism?........................

Please be aware that all information supplied with this application will be available to the public, unless

required to be kept confidential pursuant to state or federal law.

I CERTIFY UNDER PENALTY OF UNSWORN FALSIFICATION PURSUANT TO AS 11.56.210 THAT THE

STATEMENTS IN THIS APPLICATION ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Signature

ATTACH RECENT PHOTOGRAPH

Date of Application

(Taken within the last

six months)

No larger than 3 x 3

NOTICE: Portion of the Notary Seal must overlie the

photograph.

SUBSCRIBED AND SWORN to before me this ______ day of

NOTARY SEAL

Notary Public

My Commission Expires:

08-4400 (New 11/99)

Form 08-4400 - Application For Dietitian License Page 2