APPLICATION FOR LICENSED DIETITIAN/NUTRITIONIST

APPLICATION
FOR
LICENSED DIETITIAN/NUTRITIONIST
In accordance with Louisiana state law, you may not begin work until your license
has been issued.
Dear Applicant:
Attached is an application packet for licensure as a Licensed Dietitian/Nutritionist. Included in the packet is a copy of LRS 37:3081 through 3093 and LRS 36:259 (U) and
the Board’s Rules and Regulations.
Effective July, 1, 1988, no person shall use the titles “dietitian”, “dietician”, “nutritionist”,
“licensed dietitian”, “dietician” or “licensed nutritionist”, or use the designation “LD”, or
“LN”, or any other abbreviation or facsimile thereof unless he/she is licensed in accordance with the provisions of the Louisiana Dietetics/Nutrition Practice Act of 1987. Further, no person shall practice dietetics/nutrition or provide nutrition care services unless
licensed or otherwise authorized to practice in accordance with the Dietetics/Nutrition
Practice Act.
If you cannot qualify in accordance with LRS 37:3086 (see enclosed law), you may
qualify for a provisional license. Please contact the Board office at 225-756-3490 for
more information concerning the provisional license.
If you have ever held a license as a dietitian and/or nutritionist in another state, you
must have that State Board complete and return a “Verification of Licensure” form.
Annual License Renewal Forms are mailed in April. License renewals are due by June
30th of each year. Licensees must present proof of holding current CDR registration or
proof of having completed 15 hours of continuing education to be submitted on Form E
(Summary of Continuing Education).
Please allow at least four (4) weeks for the processing of your license application.
Louisiana Board of Examiners in Dietetics and Nutrition
18550 Highland Road, Suite B ΠBaton Rouge, LA 70809
Telephone: (225) 756-3490 ΠFax: (225) 756-3472 ΠWebsite: www.lbedn.org
INSTRUCTION SHEET
1.
2.
Read the Louisiana Dietetic/Nutrition Practice Act, (L.R.S. 37:3081 through 3093 and L.R.S.
36:259 (U)) before filling out this application. Please complete appropriate forms and follow the
instructions provided.
a.
TYPE or PRINT IN INK LEGIBLY. Use additional pages as necessary throughout the form
if sufficient space is not provided.
b.
List name on each of the forms.
c.
The Application Form MUST BE NOTARIZED.
d.
If not currently employed, check the box in “Current Primary Employment Information”.
e.
Academic Training Form (C), if required.
Send only official transcripts of relevant college work.
List maiden or other married names appearing on your transcript(s) if different from
the applicant name.
FEE SCHEDULE:
Licensed Dietitian/Nutritionist = $90.00
Includes $45.00 non-refundable application fee and $45.00 initial license fee.
License Reciprocity = $115.00
For applicants who hold, or who have held a dietetic/nutritionist license in another state.
Includes $45.00 non-refundable application fee, $45.00 initial license fee and $25.00 reciprocity fee. RDs may apply as Licensed Dietitian/Nutritionist.
Provisional Licensed Dietitian/Nutritionist = $95.00
Includes $45.00 non-refundable application fee and $50.00 initial license fee.
Make Check/Money Order Payable to: LBEDN
Mail completed notarized and signed application, material, and fee to:
LOUISIANA BOARD OF EXAMINERS IN DIETETICS AND NUTRITION
18550 HIGHLAND ROAD, SUITE B
BATON ROUGE, LA 70809
LOUISIANA BOARD OF EXAMINERS IN DIETETICS AND NUTRITION
18550 Highland Road, Suite B ΠBaton Rouge, Louisiana 70809
Office: (225) 756-3490 Œ Fax: (225) 756-3472 Œ Website: www.lbedn.org Œ Email: [email protected]
APPLICATION FOR
LICENSED DIETITIAN/NUTRITIONIST
1.
Applicant’ Name: ____________________________________________________________
2.
Name on transcript if different from #1 ___________________________________________
3.
Date of Birth: ______________________ 4. SS#_________________________________
5.
Home Address: _____________________________________________________________
(Required by LRS 37:23)
(Street or Box Number)
___________________________________________________________________________________________________
(City)
(State)
(Zip)
6.
Parish of Residence:____________________ 7. Email Address:______________________
8.
Work Address: ______________________________________________________________
(Street or Box Number)
9.
Telephone:
(City)
(State)
(Zip)
Home: (_____)____________________ Work: (_____)___________________
10. Drivers License No: __________________________________________________________
11.
Are you a Registered Dietitian?
YES ______NO ______
If YES, registration number: ____________________
Submit copy of current CDR Identification card.
12.
Have you ever possessed a professional license or certificate
YES ______NO ______
issued by another state(s)? List all states that you have previously (If yes, submit Verification of
License from each state)
held licensure: _______________________________
13.
Has any state rejected your application or revoked or YES ______NO ______
(If yes, attach notarized
suspended your professional license or certificate?
explanation)
14.
Have you ever been charged or convicted of any crime or YES ______NO ______
(If yes, attach notarized
unprofessional conduct?
explanation)
15.
To an extent that it impairs your functioning as a dietitian or YES ______NO ______
nutritionist, have you ever used or are you currently using (If yes, attach notarized
drugs, chemical substances (including controlled substances explanation)
obtained either with or without a valid
prescription), or
intoxicating liquors?
16.
Have you been a participant in an alcohol or drug treatment or YES ______NO ______
rehabilitation program in which you were monitored or (If yes, attach notarized
explanation)
supervised relative to your use of drugs or alcohol?
17.
Have you ever been adjudged mentally incompetent?
YES ______NO ______
(If yes, attach notarized
explanation)
Continued Î
LDN Application
Rev. 5/2008
Act # 721 passed by the Louisiana Legislature in the 2003 Regular Session, mandates that State Licensing
Boards ask the following questions. The information given is to remain confidential, and will be used to
measure and track the supply of licensed professionals for statistical purposes by the Louisiana Department of Labor.
18.
Employment in Dietetics/Nutrition:
† I am employed or self-employed in Dietetics/Nutrition:
† Part time (less than 36 hrs per week as defined by the Department of Labor).
† Full time (36-40 hrs per week as defined by the Department of Labor).
† I am not employed in the profession of Dietetics/Nutrition.
19.
† I am employed or self-employed in LA.
† I am employed in the profession out of LA.
OPTIONAL:
20.
I graduated with my degree in Dietetics/Nutrition in 2008. †
21.
I moved to LA and obtained my license in 2008. †
22.
I am:
White †
Black/African American †
Hispanic †
Asian †
Other †
CURRENT PRIMARY EMPLOYMENT INFORMATION
† I am not currently employed in the field of dietetics/nutrition.
23.
Employer: _________________________________________________________________
Address: __________________________________________________________________
__________________________________________________________________________________________
(City)
(State)
(Zip)
Telephone:(_____)________________________ Email Address:_________________________________
Job Title: _________________________________________________________________________________
Dates of Employment: From ______________________ to __________________________
(Mo/Day/Yr)
(Mo/Day/Yr)
**PLEASE NOTE: Formal Job Description must be included as part of the Application.
If you are not currently employed, please check applicable box above.**
NOTARIZED DECLARATION
PLEASE READ CAREFULLY AND HAVE NOTARIZED
In making application to the Louisiana State Board of Examiners in Dietetics and Nutrition for the issuance of a license as a Licensed Dietitian/
Nutritionist, I have read and agree to abide by the R.S. 37:3081 through R.S. 36:259 (U). I also agree to complete application requirements
and take examinations necessary for the processing of my application. I further understand that the application fee is nonrefundable and that
the materials submitted for consideration become the property of the Board and are nonreturnable. I am aware of the schedule of fees and
understand that additional fees must be paid to keep the license current.
I agree to hold the Louisiana Board in Dietetics and Nutrition, its members, officers, agents and examiners free from any damage or claim for
damage or complaint by reason of any action they or any one of them take in connection with this application or the failure of the Board to
issue me a license and any other aspect of licensing. I hereby grant permission to the Board to seek any information or references it deems
fit in securing my credentials pertinent to this application.
I further agree that if issued a license, upon the revocation, suspension or cancellation of that license, I shall return the license certificate and
license identification card to the Board. The information which I have provided in this application is truthful. I understand that providing false
information of any kind may result in the voiding of this application, and my failing to granted a Licensed Dietitian/Nutritionist, or the revocation
of my license.
Sworn to and subscribed before me, undersigned Notary, this ______ day of ____________________,
20____.
Applicant’s Signature: ______________________________________________
SEAL
Notary Public:_____________________________________________________
ID#
Applicant Name: ________________________________
LICENSED DIETITIAN/NUTRITIONIST
ELIGIBILITY ROUTE
CHECK ONLY ONE ELIGIBILITY ROUTE FOR LICENSURE AND SUBMIT ALL THE FORMS
INDICATED.
A.
Applicant is currently registered with Commission on Dietetic Registration (CDR).
Submit this form, as well as the Application, and a photocopy of the current ID
card issued by CDR.
B.
If Applicant is currently licensed by another state or has held a license in another state. Must submit this Form, as well as the Application, and Verification of
Licensure for each state you hold or have held a license to practice Dietetics
and/or Nutrition.
C.
Applicant holds a baccalaureate or higher degree with a major course of study in
human nutrition, food/nutrition, dietetics or food system management and has
completed all of the following requirements:
1.
Planned experience approved by the American Dietetic Association or the Louisiana Board of Examiners in Dietetics and Nutrition
(LBEDN).
2.
The Board recognizes and accepts a passing score on the Registration Examination for Dietitians of the Commission on Dietetic
Registration (CDR) as the Board’s licensure examination.
Submit this Form, as well as, the Application. Submit with official transcripts and
verification of examination from CDR.
FORM A
5/2008
Directions for Applicant:
Complete front portion of form and forward one to each state where
you hold or have held a license, to practice Dietetics and/or Nutrition.
Your application for a Louisiana license will not be processed until the
forms are returned to our office.
_____________________________________
State Board
I am applying for a license to practice dietetics/nutrition in Louisiana based on endorsement. I
was granted license number___________ on____________________ by the State of
__________________________.
The Louisiana Board of Examiners in Dietetics and Nutrition request that I submit verification
that my license in the State of ___________________________ is in good standing.
You are hereby authorized to release any information in your files, favorable or otherwise, directly to the Louisiana Board of Examiners in Dietetics and Nutrition. Your prompt attention will
be appreciated.
Signature: ________________________________________________
Print Name: _______________________________________________
Address:__________________________________________________
City, State, Zip:_____________________________________________
Date:_____________________________________________________
VERIFICATION OF LICENSURE
Directions for State Board: Please complete and return this form to the Louisiana Board of
Examiners in Dietetics and Nutrition at 18550 Highland Road, Ste. B, Baton Rouge, LA
70809.
Name of Licensee: __________________________________________________________
License Type: ______________________________________________________________
License #: _______________________ Date Issued: ______________________________
Please list the requirements that were met by the Licensee in order to obtain the license.
______ Current Registration with the Commission on Dietetic Registration (CDR)
______ Receipt of a baccalaureate or higher degree from an accredited college or uni
versity with a major course of study in human nutrition, food and nutrition, die
tetics or food systems management.
______ Completion of a program of experience of not less than nine hundred
supervision hours.
______ Satisfactory completion of Examinations:
______ CDR
______ State Prepared
Is the License current?
____ Yes
____ No
Critical Information?
____ Yes ____ No
If yes, please explain________________________________________________________
__________________________________________________________________________
Other comments: __________________________________________________________
__________________________________________________________________________
Signature:_______________________________________
Name (printed): __________________________________
Title of Official:___________________________________
SEAL
Board Name: ____________________________________
Address:________________________________________
________________________________________
Date Completed:_________________________________
FORM D
5/2008