Fillable Rd App (Commonwealth of Massachusetts)

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Rd App (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Revised app. 7-15-09
MASSACHUSETTS BOARD OF REGISTRATION OF DIETITIANS AND NUTRITIONISTS
Important Information and Instructions for Application for
Licensure as a Dietitian/ Nutritionist
For Current REGISTERED DIETITIANS
(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 or higher from an accredited school with
a major course of study in dietetics and nutrition, human nutrition, nutrition education, or public health
nutrition, or with a reasonable threshold of undergraduate level academic credit hours in nutrition and
nutrition sciences as determined by the Board. An official transcript in an unopened, registrar-sealed
envelope must accompany your application.
2.) If you answered 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.) You must provide documentation of your current status as a Registered Dietitian. Please be sure to
include a photo copy of your CDR registration card so that the Board may perform an online verification.
In lieu of the copy of your CDR card, you may also submit an official letter of verification from CDR in
an unopened, sealed envelope..
4.) Your application 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.
5.) Your application must be notarized.
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.
Revised app. 7-15-09
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: ___________________________________________________
School Location: _________________________________________________
9. Professional Experience:
Number of Years of Paid Professional Practice: ________________
Location of formal internship (if any): _____________________________________________________
Revised app. 7-15-09
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):
__________________________
13. 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):
__________________________
14. 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.}
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_________________
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:
1
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:
1
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:
1
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).
Page 2 of 2
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Rd App (Commonwealth of Massachusetts)

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Completed 27 July 2020

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