Form 08-4400 - Application For Dietitian License Page 3
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3State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Dietitian Licensing
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2580
E-mail: license@dced.state.ak.us
VERIFICATION OF LICENSURE
APPLICANT: COMPLETE TOP HALF OF THIS FORM AND FORWARD IT TO ALL STATES WHERE YOU ARE
OR HAVE BEEN LICENSED.
I am applying in Alaska for a license to practice dietetics. Alaska requires certification of the status of my license in
each jurisdiction in which I hold or have held licenses.
Last Name
First Name
Middle
Social Security Number
Mailing Address
License Number
Daytime Telephone:
City
State
Zip Code
I hereby request and authorize the State of
to provide any and all pertinent
information requested in this form to the Alaska Division of Occupational Licensing to complete an application filed
with that agency.
Applicant Signature
Date
TO STATE BOARD
Please complete the bottom half of this form and return it directly to the Alaska Division of
Occupational Licensing at the address listed above.
Licensing Jurisdiction:
License Type:
Dietitian
Nutritionist
Other:
Name of Licensee:
Licensed By (reciprocity, examination, etc.):
License Number
Original Issue Date
Expiration Date
Periods of Lapse
Has the license ever been revoked, suspended, placed on probation, or restricted in any way?
Yes
No
Has the licensee ever been the subject of an unresolved complaint, review procedure, or disciplinary action?
Yes
No If yes, please enclose an explanation or documentation.
Comments:
Name
Signed
SEAL
Title
Date
08-4400a (New 11/99)
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