Renewal - Louisiana Board of Examiners in Dietetics and Nutrition

Louisiana Board of Examiners in Dietetics and Nutrition
18550 Highland Rd., Suite B · Baton Rouge, LA 70809 · (225) 756-3490 · www.lbedn.org
2015-2016
RENEWAL APPLICATION
FOR
LICENSED DIETITIAN/NUTRITIONIST
Renewals must be submitted by June 30, 2015.
Renew online at www.lbedn.org and receive updated license card within one week. Renewals by mail may take
up to six weeks for processing.
Renewal Fee Submitted between April 15 and June 30, 2015 . . . . . . . . . . $60.00
Renewal Fee submitted between July 1 and August 31, 2015. . . . . . . . . . . $85.00
Delinquent requests for renewals will be accepted through August 31, 2015
After August 31, 2015, all individuals with lapsed licenses will be required to submit a new application and meet license requirements as stated in
LRS 37:3081-3094.
ALL FIELDS ARE REQUIRED
NAME:____________________________________________________________________________LA LICENSE #:_______________
HOME ADDRESS:_______________________________________________________________________________________________
CITY:________________________________STATE:______________ZIP:______________PARISH:____________________________
PHONE:__________________________FAX:__________________________EMAIL:_________________________________________
DRIVER’S LICENSE NUMBER:_______________________________________ SSN:_______________________________________
JOB TITLE:_____________________________________________________________________________________________________
DESCRIPTION OF EMPLOYMENT:________________________________________________________________________________
EMPLOYER’S NAME:____________________________________________________________________________________________
EMPLOYER’S ADDRESS:________________________________________________________________________________________
CITY:________________________________STATE:______________ZIP:______________PARISH:____________________________
PHONE:__________________________FAX:__________________________EMAIL:_________________________________________
Name, address, and email address can be requested by third parties to advertise continuing education opportunities. I allow only the
following to be shared. If left unchecked, all data will be shared.
□ Name & Address
□ Email Address
□ Opt out of data sharing
Employment in Dietetics/Nutrition (Check the one that applies):
□ I am employed or self-employed in Dietetics/Nutrition in Louisiana.
□ I am employed or self-employed in Dietetics/Nutrition outside of Louisiana.
□ I am not employed in the profession of Dietetics/Nutrition.
Your application is NOT considered complete until all supporting documents and fees have been
received by the Board.
Required Documents:



Application; must be completely filled out and signed.
Copy of current CDR card.
Applicable fee.
Renewal applications submitted via fax or email are unacceptable and will be subject to late penalties.
All applicants have an obligation to update and supplement the information and responses on this application if
they change. Failure to supplement the information and responses on this
application may result in denial or other appropriate action.
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1.
Has any state rejected your application or revoked or suspended your professional license or certificate?
YES ______
NO ______
(If yes, attach notarized explanation)
2.
Has any state imposed any form of disciplinary action (revocation, suspension, reprimand, fine, etc.) on
you or your professional licensure?
YES ______
NO ______
(If yes, attach notarized explanation)
3.
Have you ever been charged or convicted of any crime or unprofessional conduct?
YES ______
NO ______
(If yes, attach notarized explanation)
4.
To an extent that it impairs your functioning as a dietitian or nutritionist, have you ever used or are
you currently using drugs, chemical substances (including controlled substances obtained either with
or without a valid prescription), or intoxicating liquors?
YES ______
NO ______
(If yes, attach notarized explanation)
5.
Have you been a participant in an alcohol or drug treatment or rehabilitation program in which you
were monitored or supervised relative to use of drugs or alcohol?
YES ______
NO ______
(If yes, attach notarized explanation)
6.
Do you currently use or have you used illegal substances in the past five years?
YES ______
NO ______
(If yes, attach notarized explanation)
7.
Have you ever been adjudged mentally incompetent?
YES ______
NO ______
(If yes, attach notarized explanation)
Note: If you have pr eviously pr ovided to the Boar d notar ized explanation(s) of such incident(s) and no fur ther infor mation or chang e of status
relative to such incident(s) is available, you do not need to replicate material previously submitted to the Board during the renewal process.
Required check box
□I have not supervised a Provisional Licensed Dietitian/Nutritionist during the fiscal year J uly 1, 2014 thr ough J une 30, 2015.
□I have supervised a Provisional Licensed Dietitian/Nutritionist during the fiscal year J uly 1, 2014 thr ough J une 30, 2015.
Please complete section below (use additional paper if necessary).
Name__________________________________________________________Prov-LDN License # __________________
Is the Provisional LDN still under supervision?
□ Yes
□ No
Name of Facility: _____________________________________________City: ________________________State:______
What are the Provisional LDN’s duties at this Agency: _______________________________________________________
___________________________________________________________________________________________________
What type of supervision has the Provisional LDN received:___________________________________________________
How is the Provisional LDN progressing with the Registered Dietitian examination?_______________________________
___________________________________________________________________________________________________
When is the last time the RD examination was attempted: _____________________________________________________
The Provisional LDN’s license will expire on: ______________________________________________________________
Required check box
□I hereby certify to the Louisiana Board of Examiners in Dietetics and Nutrition that the above statements are true and correct to the best
of my knowledge. I understand that if this supervisory relationship changes, I must notify the Board within (30) days of such change.
I hereby request that my license to practice in Louisiana be renewed. I certify that the information I have
provided is true and correct. If you are unable to certify this statement, you must attach a notarized
explanation.
Signature:_____________________________________________________ Date:_________________________
Payments may be made via check or credit card. If you wish to pay via credit card, the following information must be completed. An additional $3.00 processing charge will be added to the charge amount.
Name on Card: _______________________________________________________
Card Number:
Expiration Date:
Or Make Check Payable to:
___
___
__
___
3-Digit Security Code:
LBEDN
18550 Highland Road, Suite B, Baton Rouge, LA 70809
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