Looking for a Alaska Legal Forms And Templates? Download it for free!

Form 08-4399d - Verification Of Experience - Department Of Community And Economic Development Page 2

VERIFICATION OF EXPERIENCE

SECTION II: TO BE COMPLETED BY SUPERVISOR. (Please type or print)

INSTRUCTIONS TO SUPERVISOR:

1. Read carefully the applicant’s Report of Experience on the front side of this form.

2. If you disagree with any information presented by the applicant on this form, or wish to provide any other

information for consideration by the department relative to the applicant, please submit a separate letter

with this form. If you do so, please identify applicant by full name and social security number in your letter

and indicate that he/she is an applicant.

3. Complete and sign the supervisor’s affidavit below, or if you do not sign the affidavit, please explain why in

a separate letter attached to this form.

4. DO NOT RETURN ORIGINAL TO APPLICANT.

State of Alaska

Mail completed form directly to address at right.

Department of Community and

Economic Development

Division of Occupational Licensing

Nutritionist Licensing

P.O. Box 110806

Juneau, AK 99811-0806

Supervisor’s Name:

Current Address:

Street/P.O. Box

City

State

Zip Code

Daytime Telephone:

WITH RESPECT TO THE APPLICANT’S REPORT OF EXPERIENCE AS DESCRIBED ON THE FRONT OF

THIS FORM:

1. Does that description accurately reflect the work personally performed by the applicant?

Yes

2. Does the time claimed by the applicant for this experience reasonably reflect actual time?

Yes

3. Briefly identify your work relationship to the applicant at the time. (If none, explain.)

SUPERVISOR’S AFFIDAVIT

I have read the applicant’s Description of Experience. I hereby certify that I am knowledgeable about, and

qualified to attest to, the applicant’s work and that, except as otherwise noted on this form, or in attached

correspondence, the work experience described by the applicant and the time claimed is true and accurate.

I cannot so certify.

Supervisor’s Signature

Date

08-4399d (New 11/99)

Form 08-4399d - Verification Of Experience - Department Of Community And Economic Development Page 2