Form 08-4399d - Verification Of Experience - Department Of Community And Economic Development

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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
VERIFICATION OF EXPERIENCE
SECTION I: TO BE COMPLETED BY APPLICANT: After completing Section I, make a copy for your
records, and forward the original form to your supervisor. (Please type or print legibly.) This form must be
submitted to each entity (i.e., supervisor, employer, peer, etc.) under which you obtained experience.
Name:
Last
First
Middle
Address:
Street/P.O. Box
City
State
Zip Code
Daytime Telephone:
Social Security Number:
Date of Birth:
Experience described below was obtained while employed by:
Organization Name:
Address:
Street/P.O. Box
City
State
Zip Code
Beginning:
and ending
Total Hours of Experience:
Experience in:
Human Nutrition
Human Nutrition Research
Both
Describe in the space below your nutritionist duties during your employment with the organization
named above.
I hereby certify that the work experience described above and the time claimed for that experience is true and
accurate.
Applicant’s Signature
Date
SUPERVISOR MUST COMPLETE SECTION II ON THE REVERSE SIDE
08-4399d (New 11/99)

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