Dietetics And Nutrition Form 4c - Report Of Planned Work Experience Page 2
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2SECTION II: TO BE COMPLETED BY SUPERVISOR OR INTERNSHIP COORDINATOR. (Please type or print)
INSTRUCTIONS TO SUPERVISOR OR INTERNSHIP COORDINATOR:
1. Read the applicant's Report of Experience from page 1 of this form carefully and complete the following information.
2. Return this form directly to the Office of the Professions at the mailing address at the end of this form. This form will not be
accepted if returned by the applicant.
1
Print Full Name Of The Acceptable Dietitian Or Nutritionist Supervising The Planned Work Experience.
___________________________________________________________________________________________________________
Last
First
Middle
2
Address
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
3
Daytime Phone
Telephone
E-Mail Address (Please print clearly)
Number:
Area Code
Phone Number
4
Are you registered in New York State as a certified Dietitian or Nutritionist?
Yes
No
Application submitted
If “Yes,” certificate number ____________________________________
5
Provide the name of any national dietetic or nutrition association in which you are currently registered or are a member and the date of
registration/membership. If you are not NYS certified, please attach a photocopy of your national registration/membership document.
National Dietetic or Nutrition Association
Date of current Registration/Membership
Type of Registration/Membership
CERTIFICATION
I have read the applicant's description of this experience and find that description to be generally true and accurate. I hereby attest that this
was a diverse and continuous work experience in dietetics and nutrition which reflected increased levels of professional growth.
_______________________________________________________________________
______________________________________
Signature of Supervisor/Internship Coordinator
Date
If you cannot sign the certification or 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 of explanation 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.
A separate letter is enclosed.
Yes
No
Return Directly to: N ew York State Education Department, Office of the Professions, Dietetics-Nutrition Unit, 89 Washington Avenue, Albany, NY 12234-
1000.
Dietetics-Nutrition Form 4C, Page 2 of 2, Rev. 09/04
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