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Certified Nutrition Specialist Verification Form - Department Of Community And Economic Development

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

CERTIFIED NUTRITION SPECIALIST VERIFICATION

Complete Section A of this form and submit it to the Certification Board of Nutritional Specialists (CBNS) for

completion of Section B. They will in turn mail this form directly to the division at the address listed above.

CBNS telephone (212) 777-1037.

SECTION A

Name:

Last

First

Middle

Mailing Address:

Street/P.O. Box

City

State

Zip Code

Daytime Telephone:

Social Security Number:

Date of Birth:

Your name at time of examination, if different:

, hereby authorize the Certification Board of Nutrition

Print Name

Specialists to release all information requested on this form to the Alaska Division of Occupational Licensing.

Signature

SECTION B

, certify that

Name of CBNS Representative

Candidate Name

has passed the Certified Board of Nutrition Specialists Certifying Examination and is currently a Certified

Nutrition Specialist.

Initial Certification Date:

Expiration Date:

Signature

SEAL

Title

Date

08-4399b (New 11/99)

Certified Nutrition Specialist Verification Form - Department Of Community And Economic Development