ARKANSAS
P.O. BOX 1016,
NORTHROCK AR 72115
501-580-9294
http://www.ardieteticslicbrd.net
STATE OF ARKANSAS
NAME______________________________
PLEASE READ CAREFULLY
In making application to the
Arkansas Dietetic Licensing Board for the issuance of a license or provisional
license as a Dietitian, I have read and agree to abide by the Dietetics
Practice Act and the Rules and Regulations of the Arkansas Dietetics Licensing
Board. I also agree to complete all application requirements
and take all examinations necessary for the processing of my
application. Upon issuance of a license, I agree to be bound
by the Standard of Professional Responsibility as set forth in the Rules and
Regulations. I further understand that the fee submitted with
this application is nonrefundable and that the materials submitted for
consideration become the property of the Board. I am aware of
the schedule of fees and understand that additional fees must be paid to
maintain licensure.
I agree to hold the Arkansas Dietetics Licensing Board, its members, its
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 may take in
connection with this application, the examination (if applicable), the failure
of the Board to issue me a license, or 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, or expiration of that license, I shall return the license
certificate and license identification 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 be
granted a license or provisional license, or the revocation of my license.
___________________________ _______________________________________________________
Date
Signature
of Applicant
THE STATE
OF )
COUNTY
OF )
BEFORE
ME, the undersigned authority, on this day personally appeared
_________________
known to me to be the person whose name is subscribed to the foregoing
instrument, and having
been by me first duly sworn an oath, acknowledged that he/she had executed the
same for the
purposes and consideration therein expressed and that the foregoing statements
are true and corrected.
GIVEN under my hand and seal of office, this _____ day of
_______________20 ____.
Notary Public in and for
___________________________________
(Signature of Notary)
___________________________________
(Name of Notary)
___________________________________
(Commission Expiration Date)
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ADLB-3 06/07 |
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