Dietetics And Nutrition Form 4c - Report Of Planned Work Experience
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1
2The University of the State of New York
Dietetics-Nutrition Form 4C
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
REPORT OF PLANNED WORK EXPERIENCE
SECTION I: TO BE COMPLETED BY APPLICANT. Complete Section I and make a copy for your records. Forward the original form to your supervisor
to complete Section II. Associate Degree applicants must identify the supervisor’s name from the list provided on Form 4. If your experience was
completed in an internship program, Section II should be completed by the internship coordinator.
Name:
Last
Social Security Number:
First
Middle
Mailing
Line 1
Birth Date:
Address:
Line 2
mo .
day
yr.
Line 3
City
State
Zip Code
Country/
Province
Telephone/E-Mail:
Daytime Phone
E-Mail Address (Please print clearly)
Area Code
Phone Number
Supervisor’s/Internship Coordinator’s Name: _________________________________________________________________________
Experience described below was obtained while employed by or as an internship sponsored by:
Organization Name: ______________________________________________________________________________________________
Address:
Street
________________________________________________________________________________________
________________________________________________________________________________________
City
____________________________________________ State _____________ Zip code __________________
Beginning _____ / _____ / _____ and ending _____ / _____ / _____ at __________ hours per week.
mo.
day
yr.
mo.
day
yr.
Describe in the space below your dietetic/nutrition 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 are true and accurate.
_______________________________________________________________________
______________________________________
Applicant's signature
Date
Dietetics-Nutrition Form 4C, Page 1 of 2, Rev. 09/04
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