Dietetics And Nutrition Form 4b - Report Of Experience Record (Page 2 of 2) in pdf

SECTION II: TO BE COMPLETED BY SUPERVISOR. (Please type or print)

INSTRUCTIONS TO SUPERVISOR: 1.

Read carefully the applicant's Report of Experience on the previous page of this form

and provide the requested information.

If you are not NYS certified, attach a photocopy of the national

registration/membership that you hold.

Return this form directly to the Office of the Professions at the mailing address at the

end of this form. This form will not be accepted if returned by the applicant.

Supervisor's Name: ________________________________________________________________________________________________

Address:

Line 1

Line 2

Line 3

City

State

Zip Code

Country/

Province

Telephone

Daytime Phone

E-Mail Address (Please print clearly)

Number:

Area Code

Phone Number

NYS Certificate Number:* __________________________________

*Attach photocopy of national registration/membership if not NYS certified.

WITH RESPECT TO THE APPLICANT'S REPORT OF EXPERIENCE AS DESCRIBED ON THE FRONT OF THIS FORM:

Does that description accurately reflect the work personally performed by the applicant?

YES

Does the time claimed by the applicant for this experience reasonably reflect actual time?

YES

Briefly identify your work relationship to the applicant at the time, such as direct supervisor or department head. (If none, explain.)

___________________________________________________________________________________________________________

_______________________________________________________________________________________________

CERTIFICATION

I have read the applicant's Report of Experience.

I hereby certify that I am knowledgeable about, and qualified to

attest to, the applicant's work and that, except as otherwise noted on this form, or in attached correspondence, the

work experience described by the applicant and the time claimed is generally true and accurate.

_______________________________________________________________________

______________________________________

Signature of Supervisor

Date

If you cannot sign the certification or disagree with any information presented by the applicant on this form, or wish to

provide any other information for consideration by the Department relative to the applicant, please submit a separate letter

with this form. If you do so, please identify applicant by full name and social security number in your letter and indicate that

he/she is an applicant.

A separate letter is enclosed.

Yes

Return Directly to: New York State Education Department, Office of the Professions, Dietetics-Nutrition Unit, 89 Washington Avenue, Albany, NY 12234-

1000.

Dietetics-Nutrition Form 4B, Page 2 of 2, Rev. 09/04

Dietetics And Nutrition Form 4b - Report Of Experience Record Page 2

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