Fill - Free fillable Non Rd App (Commonwealth of Massachusetts) PDF form

Revised app. 10-18-11

MASSACHUSETTS BOARD OF REGISTRATION OF DIETITIANS AND NUTRITIONISTS

Important Information and Instructions for Application for

Licensure as a Dietitian/ Nutritionist

(Include this sheet with your completed application)

MANDATORY:

My social security number is: □□□-□□-□□□□

Pursuant to G.L. c. 62C, § 47A, the Division of Professional Licensure is required to obtain your

social security number and forward it to the Department of Revenue. The Department of

Revenue will use your social security number to ascertain whether you are in compliance with

the tax laws of the Commonwealth.

1.) The minimum educational requirement is a Bachelor’s Degree from an accredited school. An

official transcript in an unopened, registrar-sealed envelope must accompany your application.

∞ If your degree is in dietetics and nutrition, human nutrition, nutrition education, public health

nutrition, or a similarly titled program, you will only need an official transcript verifying your

degree.

∞If your degree is in an unrelated field of study, but you have fulfilled the minimum course

requirements as set by the Regulations, you must submit the "Course Summary Form" along

with the official transcript(s) verifying successful completion of the required courses.

2.) If you answer “yes” to question #10 on the application form, a certificate of standing is

required from every licensure jurisdiction, even if your license is expired. The official

statement(s) in unopened, jurisdiction-sealed envelope(s) must accompany your application.

3.) Verification of your completion of the required supervised professional experience must be

submitted. Be sure to have the “Verification by Supervisor” form completed and to submit

that along with a current resume demonstrating compliance with the applicable experience

requirements.

Experience Requirements:

 3 years of full time paid professional experience with a bachelors degree

 2 years of full time paid professional experience with a masters degree

 1 year of full time paid professional experience with a doctorate degree

 Board approved internship

Please note that in order for the Board to determine that the paid professional experience

Revised app. 10-18-11

is acceptable it must demonstrate practice that falls within the appropriate standards of

practice and activities identified in the Regulations 268 CMR, 5.01, which can be found on

the Board’s website at www.mass.gov/dpl/boards/nu.

4.) All applicants are required to take and pass a Board approved examination. Following Board

approval of your application you will be notified of your eligibility to sit for the RD examination

given by the Commission Dietetic Registration. Instructions on how to register will be provided

at that time. You may not

Please note that while completion of the entire RD examination is required, applicants need only

to pass domains I, II, and III.

As of January 1, 2012 the test specifications of the RD examination have been re-organized.

Exams taken after this date will require passage of domains I and II.

Alternatively the Board does accept passage of the Certification Board for Nutrition Specialists

(CBNS) examination in lieu of the above. If you have passed the CBNS exam a verification of

your passage must be received along with your application. An official letter from CBNS in an

unopened, sealed envelope must accompany your application.

5.) Your application, which must be notarized, will not be processed without the required fee of

$196.00

in the form of a U.S. check or U.S. money order payable to the Commonwealth of

Massachusetts. This fee, which is non-refundable, includes both the application processing fee

and your initial licensure fee. Your license will expire after two years on your birthday.

Renewal must occur not later than your expiration date, which will be indicated on the license.

Course Summary Form Instructions:

In accordance with the Board’s Statutes and Regulations, all applicants must possess a bachelor's

degree, its equivalent, or higher. If this degree is in an unrelated field, completion of the

following must be shown:

Biological Sciences-- 9 semester hours, which must include:

Human Anatomy and Physiology (or equivalent) and

Microbiology (or equivalent)

and

Chemistry--6 semester hours, which must include:

Biochemistry (or equivalent)

and

Behavioral Sciences--3 semester hours, which may include but is not limited to:

Psychology, Sociology, Cultural Anthropology, Counseling, or Ed. Psychology

and

Revised app. 10-18-11

Foods and Nutrition--24 semester hours, which must include at least 3 semester hours in each

of the following categories:

a. Diet Therapy, Medical Dietetics, Clinical Nutrition, or equivalent.

b. Nutrition through the Life Cycle, Applied Human Nutrition, Advanced

Human Nutrition (or equivalent).

c. Foods, Food Science, Food Composition and Menu Planning, Food Service

Management (or equivalent).

On the provided Course Summary Form, specify the course number, title and credits awarded for

those courses that were successfully completed to meet the above noted requirements. Please be

sure to identify whether semester hour or quarter hour credit was granted. Each course must be

reflected on your official transcript(s).

Please be aware that:

You must provide the Board with a valid, USPS acceptable address and be sure to keep this

address up to date with the Board. Please be advised that the address you choose as your official

mailing address is a matter of public record and will be released to anyone upon request.

All applicants must have a valid Social Security number or U.S. Tax Identification Number

(ITIN).

Mail all application materials to:

Board of Dietitians and Nutritionists

1000 Washington Street, Suite 710, Boston, MA 02118-6100

Revised app. 10-18-11

The Commonwealth of Massachusetts

Division of Professional Licensure

Board of Dietitians and Nutritionists

(617) 727- 9925

1000 Washington Street, Suite 710

Boston, MA 02118-6100

WWW.MASS.GOV/DPL/BOARDS/NU

APPLICATION FOR LICENSURE AS DIETITIAN/ NUTRITIONIST

[READ INSTRUCTIONS, THEN PRINT OR TYPE]

1. Applicant Name:

Last First Middle

Maiden Name/Other Name:

2. Permanent Address:

No. Street Apt. #

City/Town State Zip Code

3. Business/ Mailing Address (If Applicable):

No. Street Apt. #

City/Town State Zip Code

4. Which address should appear on your license? Permanent Business/ Mailing

5. Date of Birth: _____________________

6. E-mail: _________________________________

7. Telephone Number-Day: ___________________________Evening:

8. Educational Background:

Highest Relevant Degree: ____________________ Year: _____________

Academic Major: ________________________________________________

School Name: ___________________________________________________

Revised app. 10-18-11

9. Professional Experience:

Number of Years of Paid Professional Practice: ________________

Location of formal internship (if any):

_____________________________________________________________________________

10. List all professional licenses/certifications you have held in the United States, or any country

or foreign jurisdiction, and the state/jurisdiction from which the license/certification was

originally issued. Enclose a certificate of standing from each state or jurisdiction in which you

have been licensed/certified, indicating the status of your license and any disciplinary

information.

11.

Has any disciplinary action been taken against you by a licensing/certification board located

in the United States or any country or foreign jurisdiction? Yes:

No:

If yes, please state the details (use a separate sheet if necessary):

12.

Are you the subject of pending disciplinary actions by a licensing/certification board located

in the United States or any country or foreign jurisdiction? Yes: No:

If yes, please state the details (use a separate sheet if necessary):

. Have you ever voluntarily surrendered or resigned a professional license to a

licensing/certification board in the United States or any country or foreign jurisdiction? Yes:

No: If yes, please state the details (use a separate sheet if necessary):

. Have you ever applied for and been denied a professional license in the United States or any

country or foreign jurisdiction? Yes:

No: If yes, please state the details (use a separate

sheet if necessary):

15.

Have you ever been convicted of, or admitted to, a felony or misdemeanor in the United

States or any country or foreign jurisdiction, other than a traffic violation for which a fine of less

than $200.00 was assessed? Yes: No: If yes, please state the details (use a separate

sheet if necessary):

__________________________

{The Board is certified by the Criminal History Systems Board [ID# MAREG G] to access data

about convictions and pending criminal cases. Those records-and other Federal and professional

records-may be checked as part of your licensing process. No records are automatic disqualifiers;

you will be given an opportunity to discuss any issues with the Board.}

Revised app. 10-18-11

I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this

application for licensure is truthful and accurate. I understand that the failure to provide accurate

information may be grounds for the Massachusetts Board of Registration of Dietitians and Nutritionists to

deny me the right to sit as a candidate or to suspend or revoke a license issued to me in accordance with

Massachusetts Law. I further attest that, pursuant to G.L. c. 62C, s. 49A., to the best of my knowledge

and belief, I have filed all Massachusetts tax returns and paid all Massachusetts taxes required by law.

Signature of applicant Date

Notary Name (print)

Notary Signature

Commission expires_________________

MASSACHUSETTS BOARD OF REGISTRATION OF DIETITIANS AND NUTRITIONISTS

Revised app. 10-18-11

Application for licensure as a Dietitian/ Nutritionist

Verification by Supervisor

SUPERVISION REFERENCE FORM

Top section to be completed by Licensure Applicant:

I, ___________________________________(Print Name of Applicant), hereby authorize

_______________________________(Print Name of Supervisor) to provide to the Board of

Registration of Dietitians and Nutritionists any information deemed relevant to my qualifications as an

applicant. I hereby release and discharge the supervisor completing this document from all claims arising

out of the provision of such information.

Applicant's Signature and Date

******************************************************************************

Remainder of this form to be completed by SUPERVISOR: Only complete this

form if the applicant has completed the waiver above. The Board assumes that you, in

recommending this applicant, would be willing to interpret or to discuss your recommendation if

the Board should desire to contact you at a later date. After you have completed this form,

please return it to the applicant.

I, ___________________________________(Print Name of Supervisor) , certify that I

supervised paid professional nutritional practice of the above named individual.

That practice was performed at:

Business Name: __________________________________

Street Address: __________________________________

City/State/Zip: __________________________________

The license applicant worked ___________ hours per week for ___________ number of weeks. Paid

professional experience began on _____________________ and ended _______________________. The

title of the applicant's position was _______________________________________________. Duties and

responsibilities included:

________________________________________________________________________________________

___________________________________________________. To the best of my knowledge, the applicant

exhibits appropriate professional competence and is of good moral character: Yes No (if no, please

explain on a separate sheet)

_______________________________________________________________________________________________________________

Supervisor’s Signature Date Phone Number

Revised app. 10-18-11

MASSACHUSETTS BOARD OF REGISTRATION OF DIETITIANS AND NUTRITIONISTS

Application for licensure as a Dietitian/ Nutritionist

Course Summary Form (see instructions prior to completion)

Course

Number

Course Title Credit

Specify Sem or

Qtr

Biological Sciences

• Anatomy/Physiology

• Microbiology

• Elective

Chemistry

• Biochemistry

• Elective

Behavioral Sciences

Foods and Nutrition

• ≥3 Hrs. Diet Therapy, Medical Dietetics,

Clinical Nutrition

• ≥3 Hrs. Nutrition through the Life Cycle,

Applied Human Nutrition, Advanced Human Nutrition

• ≥3 Hrs. Foods, Food Science, Food Composition

and Menu Planning, Food Service Management

• Elective

≥9 HRS

≥6 HRS

≥24 hrs

≥3 HRS

CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGEMENT FORM

The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to

M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of

M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified

prospective license applicants and current licensees.

As a license applicant or current licensee, I understand that a CORI check will be submitted for my

personal information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby

acknowledge and provide permission to the Division of Professional Licensure to submit a CORI check

for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I

may withdraw this authorization at any time by providing the Division of Professional Licensure written

notice of my intent to withdraw consent to a CORI check.

FOR LICENSING PURPOSES ONLY:

The Division of Professional Licensure may conduct subsequent CORI checks within one year of the

date this Form was signed by me. If subsequent CORI checks are necessary, the Division of

Professional Licensure will provide me with written notice of the subsequent CORI checks.

By signing below, I provide my consent to a CORI check and acknowledge that the information provided

on Page 2 of this Acknowledgement Form is true and accurate.

_________________________________ _________________________________

Signature Date

Please provide the name of the board of registration and license type for which you are applying or currently hold:

_________________________________ _________________________________

Board of Registration License Type

NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS

EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL

EMPLOYEE WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE

IDENTIFICATION, OR (2) SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE

VERIFIED IDENTITY AND THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES

AT THE ADDRESS SET FORTH ABOVE.

Page 1 of 2

SUBJECT INFORMATION: (An asterisk (*) denotes a required field)

________________________ _________________________ _______________________ ______

*Last Name *First Name Middle Name Suffix

___________________________________________________________________________________

*Maiden Name (or other name(s) by which you have been known)

___________________ ____________________________

*Date of Birth Place of Birth

*Last Six Digits of Your Social Security Number: ______ - _____________

Sex: ______ Height: ____ ft. ____ in. Eye Color: ___________

Driver’s License or ID Number: ___________________ State of Issue: ________________________

Current and Former Addresses:

______ ____________________________________ ______________________ _____ ________

Number Name City/Town State Zip

______ ____________________________________ ______________________ _____ ________

Number Name City/Town State Zip

SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the

above-referenced subject by reviewing the following form(s) of government-issued identification:

Passport State-issued driver’s license Military identification State-issued identification card

VERIFIED BY:

Name of Verifying DPL Employee (Please Print)

Signature of Verifying DPL Employee (Please Print) Date

SECTION B: VERIFICATION BY NOTARY:

On this ______ day of _____________, 20____, before me, the undersigned notary public, personally

appeared _________________________________ (name of document signer), and proved to me

through satisfactory evidence of identification, which was the following:

Passport State-issued driver’s license Military identification State-issued identification card

to be the person whose name is signed on the preceding or attached document, and acknowledged to

me that (he) (she) signed it voluntarily for its stated purpose.

Notary Public: Notary Commission Expires On:

If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by the other

forms of identification documentation as determined by DCJIS. 803 CMR 2.09 (2).

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