Dietetics And Nutrition Form 2 - Certification Of Professional Education
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1
2The University of the State of New York
Dietetics-Nutrition Form 2
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1.
Complete Section I. Enter your name as it appears on your Application for Certification (Form 1). Be sure to sign and date item 9.
2.
Send this form to the professional school you attended and instruct them to complete the appropriate parts of Section II of this form. Be sure to
include any fee required by the school. A separate Form 2 should be submitted for each educational program attended that will demonstrate
satisfaction of the professional education requirements.
3.
An official school transcript is required if you did not complete a New York State licensure-qualifying or a ACEND accredited program.
SECTION I: APPLICANT INFORMATION
1
2
Social Security Number
Birth Date
Month
Day
Year
(Leave this blank if you have no U.S. Social Security Number)
3
Print Your Full Name Exactly As It Appears On Your Certification Application (Form 1):
Last
First
Middle
Mailing Address
(You must notify the Department promptly of any address or name changes.)
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print name under which certificate, degree or diploma was awarded (if different from above):
____________________________________________________________________________________________________________________
6
Secondary school attended: _____________________________________________________________________________________________
7
Professional school attended: ____________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________
8
Title of certificate, diploma or degree: ______________________________________________________________________________________
Date certificate, diploma or degree was awarded: _____ / _____ / _____
mo.
day
yr.
9
I request and give my permission to the school listed in item 7 above to complete the information on this form and to send any documentation
requested (e.g., an official transcript) to the New York State Education Department's Office of the Professions.
______________________________________________________________________________________
___________________________
Applicant's signature
Date
Dietetics-Nutrition Form 2, Page 1 of 2, Rev. 12/15
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