Form 08-4399 - Application For Nutritionist License printable pdf download

Form 08-4399 - Application For Nutritionist License

NTN

State of Alaska

Department of Community and Economic Development

Division of Occupational Licensing

Nutritionist Licensing

P.O. Box 110806, Juneau, Alaska 99811-0806

(907) 465-2580

E-mail: license@dced.state.ak.us

Nonrefundable Application Fee

$ 50.00

Nutritionist License Fee

$ 410.00

Wall Certificate Fee (Optional)

$ 20.00

MAKE CHECKS PAYABLE TO: STATE OF ALASKA

APPLICATION FOR NUTRITIONIST LICENSE

INSTRUCTIONS TO APPLICANT

Each question must be answered fully, truthfully, and accurately. Any omissions, or inaccuracies are grounds

for disapproval or rejection. If the space for any answer is insufficient, the applicant may complete the answer

on a rider signed by the applicant, specifying the question to which it related. Type or print all requested data.

Name:

Social Security No.:

(Required by AS 08.01.060)

Mailing Address:

Street/P.O. Box

City

State

Zip Code

Daytime Telephone:

Date of Birth:

PROFESSIONAL STATUS (List memberships in good standing of Professional Associations.) Name/Location

OCCUPATIONAL STATUS (Past five years only.)

Position

Location

Date of Employment

LIST ALL JURISDICTIONS IN WHICH YOU HOLD OR HAVE HELD LICENSES TO PRACTICE AS A DIETITIAN OR

NUTRITIONIST

State Board

Certification Number

Date of Issue

Current Status

Exam or Reciprocity

08-4399 (New 11/99)

Form 08-4399 - Application For Nutritionist License