Dietetics And Nutrition Form 4b - Report Of Experience Record
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1
2The University of the State of New York
Dietetics-Nutrition Form 4B
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
REPORT OF EXPERIENCE RECORD
(TO BE SUBMITTED BY ASSOCIATE DEGREE APPLICANTS)
SECTION I: TO BE COMPLETED BY APPLICANT. Complete Section I and make a copy for your records. Forward the original form to your supervisor
to complete Section II. Identify the supervisor’s name from the list you provided on Form 4.
Name:
Last
Social Security Number:
First
Middle
Mailing
Line 1
Birth Date:
Address:
Line 2
mo .
day
yr.
Line 3
City
State
Zip Code
Country/
Province
Daytime Phone
Telephone/E-Mail
E-Mail Address (Please print clearly)
Area Code
Phone Number
Supervisor’s Name: _______________________________________________________________________________________________
Experience described below was obtained while employed by:
Organization Name: ______________________________________________________________________________________________
Address:
Street
________________________________________________________________________________________
________________________________________________________________________________________
City
____________________________________________ State _____________ Zip code __________________
Beginning _____ / _____ / _____ and ending _____ / _____ / _____.
Full time (35-40 hrs./wk.)
mo.
day
yr.
mo.
day
yr.
Part time ________ hrs./wk.
Describe in the space below your dietetic/nutrition duties during your employment with the organization named above.
I hereby certify that the work experience described above and the time claimed for that experience are true and accurate.
_______________________________________________________________________
______________________________________
Applicant's signature
Date
Dietetics-Nutrition Form 4B, Page 1 of 2, Rev. 09/04
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