Dietetics And Nutrition Form 2 - Certification Of Professional Education (Page 2 of 2) in pdf

SECTION II : CERTIFICATION OF EDUCATION

Name of applicant: ____________________________________________________________________________________________________

INSTRUCTIONS TO SCHOOL: Please complete: 1.

Either Part A or Part B, as appropriate; and

Part C.

Please return this form directly to the Department at the address at the end of this form. This form will not be accepted if returned by the

applicant.

PART A

– PROGRAMS REGISTERED BY NEW YORK STATE AS QUALIFYING FOR CERTIFICATION OR ACEND ACCREDITED

To be completed only by those schools at which the applicant completed a dietetics or nutrition program registered by the New York

State Education Department as qualifying for certification or accredited by the Accreditation Council for Education in Nutrition and

Dietetics (ACEND).

It is hereby certified that: ______________________________________________________________________________________________

was awarded the degree of _____________________________________________________________ on the date of _____ / _____ / _____,

mo.

day

yr.

and the curriculum completed at the time the degree was awarded was registered by the New York State Education Department as qualifying for

certification in dietetics/nutrition or was accredited by the Commission on Accreditation for Dietetics Education.

Program title ________________________________________________________________________________________________________

PART B

– ALL OTHER PROGRAMS (including ACEND – “Approved” Programs)

To be completed only by those schools in which the applicant DID NOT complete a dietetics or nutrition program registered by the New

York State Education Department as qualifying for certification nor accredited by the Accreditation Council for Education in Nutrition

and Dietetics (ACEND).

Note:

Please attach an official transcript or marksheet giving courses completed by year including grades and a syllabus of

the course of studies completed.

(1)

Length of Program: ___________________________________________________

(2)

Date of Applicant's Admission: _____ / _____ / _____

Date of Completion/Withdrawal: _____ / _____ / _____

mo.

day

yr.

mo.

day

yr.

(3)

Years of education and credential required for admission: _________________________________________________________________

(4)

Degree conferred: ________________________________________________________________________________________________

(5)

Date degree conferred: ____________________________________________________________________________________________

PART C

- CERTIFICATION

(To be completed by the Registrar)

I hereby certify that to the best of my knowledge and belief the foregoing is a true statement.

Signature: __________________________________________________________________ Date: _____ / _____ / _____

mo.

day

yr.

Type or print name: ___________________________________________________________

(COLLEGE

Title or official position: ________________________________________________________

SEAL)

Institution: ___________________________________________________________________

Location: ____________________________________________________________________

Telephone number ____________________________ Fax: ____________________________

E-mail address: _______________________________________________________________

Return Directly to: New York State Education Department, Office of the Professions, Dietetics-Nutrition Unit, 89 Washington Avenue, Albany, NY 12234-

1000.

Dietetics-Nutrition Form 2, Page 2 of 2, Rev. 12/15

Dietetics And Nutrition Form 2 - Certification Of Professional Education Page 2

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