STATE OF ARKANSAS
NAME____________________________________
PROFESSIONAL EXPERIENCE PROGRAM
INTERNSHIP DOCUMENTATION FORM FOR P.L.D. APPLICANTS
The information
on this form must be submitted to document the required
experience. The information on this form must be completed for
those applicants who are not currently registered by the Commission on Dietetic
Registration.
PLEASE TYPE OR PRINT LEGIBLY
1. Indicate
which type of experience you are documenting (Check only one):
_________Pre-planned
professional experience program approved by The American Dietetics Association.
_________Six months
full-time or 12 months half-time experience approved by the American Dietetic
Association, following completion of a baccalaureate or post-baccalaureate
degree.
_________Graduate assistantship
approved by the American Dietetic Association.
_________Internship approved by
the American Dietetic Association.
_________Coordinated
program in dietetics approved by the American Dietetic Association.
2. Name
and address of organization, agency or institution where the experience was
successfully completed:
__________________________________________________________________________________
__________________________________________________________________________________
3. Inclusive
dates of experience: From (Mo/Day/Yr):______________ To
(Mo/Day/Yr):______________
4. Name
and job title of the director or coordinator of the experience program at the
time of completion:
__________________________________________________________________________________
5. One
of the professional references on Form ADLB-5 must be the person named in #4 or
documentation must
be provided that experience was
successfully completed. The other professional reference must
be from a
registered or licensed
dietitian who is currently supervising the practice of the applicant.
|
ADLB-6 06/07 |
Last Updated
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