STEPS TO LICENSURE - Mississippi State Department of Health

STEPS TO LICENSURE DIETITIANS

Enclosed is a licensing packet for Dietitians. Two types of licensure are currently issued in Mississippi: Regular and Provisional. The requirements for each are as follows:

1. Regular

a. Completed, notarized application. b. Copy of driver's license or social security card. c. Passport style photo (copies of photos are not acceptable) d. Application fee - $100.00 (non-refundable) e. Copy of current CDR (blue) card. f. Verification of all licensure/regis tration, current or not current,

reported directly from the licensing authority (with seal).

2. Provisional (a 1 year license that may be renewed annually for 5 years)

a. Completed, notarized application. b. Copy of driver's license or social security card. c. Passport style photo (copies of photos are not acceptable) d. Application fee - $50.00 (non-refundable) e. Commission on Accreditation/Approval for Dietetics Education

Verification Statement. f. Verification of Residency form with attachments. g. Letter of supervision from th e licensed dietitian or R.D. under

whose direct technical supervision the applicant will practice. h. Verification of all licensure/regis tration, current or not current,

reported directly from the licensing authority (with seal).

All requirements must be on file and satisfactory to this office before a registration may be issued.

(Please type or print in ink)

MISSISSIPPI STATE DEPARTMENT OF HEALTH

Dietitian/Nutritionist Application for Licensure

Office Use

Check No. __________ Amount $ ___________ Date ____/____/____

License Type Regular (R.D.) q

Provisional q

1. Date: ________________________

2. Name: ________________________________________________________________________________________________

Last

First

Middle/Maiden

3. Home Address: ________________________________________

4. Telephone Number: (____) _______________

5. ____________________________________________________________ 6. ______________

City

State

Zip Code

7. Email Address: _________________________________________________________________________________________

8. Social Security Number: __________-_______-__________

9. Date of Birth: ______/______/______

10. Race: ___________ 11. Sex: Male q Female q 12. U.S. Citizen No q Yes q 13. Legal Alien No q Yes q

14. Place of Employment: _________________________________________________________________________________

15. Title of Position: ________________________________

16. Supervisor: __________________________________

17. Employment Address: ____________________________

18. Telephone Number: (____) _____________________

______________________________________________________________________________________________________

City

State

Zip Code

19. Are there any criminal or civil suits pending against you?

No q Yes q

20. Have you ever been convicted of any felony or misdemeanor?

No q Yes q

21. Have you ever had any license, registration, or certificate encumbered in any way, i.e., revoked, suspended, censured, rejected, denied, placed on probation, reprimanded, etc.? If yes, attach a full explanation including the type of license, registration, or certificate, and jurisdiction where the action occurred.

No q Yes q

22. a. Are you currently registered by the Commission on Dietetic Registration?

No q Yes q

b. CDR number: ______________________________ (attach a copy of your certification)

23. Have you ever been licensed in another state in the area of Dietetics/Nutrition?

No q Yes q

If yes, list all licenses (current/not current) including Mississippi. All licenses must be verified by the licensing authority - with board seal. (See Verification of Licensure Form.)

1. __________________ 2. __________________ 3. __________________

4. __________________ 5. __________________ 6. __________________

7. __________________ 8. __________________ 9. __________________

10. __________________ 11. __________________ 12. __________________

Mississippi State Department of Health

Revised 12-05-13 Page 1 of 5

Form 261 E

Subscribed and sworn to before me this ______ day of _____________________________, 20 ______. My commission expires _____________________.

__________________________________________

Notary Public

I, the undersigned, do solemnly swear or affirm that I am the above applicant. I have read the above application and all statements contained therein or accompanying this application are true to the best of my knowledge and belief. I have also read and understand the Regulations Governing Licensure of Dietitians and affirm that all conditions for licensure have been met and will be maintained.

_____________________________________________________________

Applicant's Signature

Notary Seal

Copy of Social Security Card or

Drivers License

Complete form, enclose fee and mail to: Mississippi State Department of Health Professional Licensure: Dietitians Post Office Box 1700 Jackson, Mississippi 39215-1700

Photo (only a Passport Photo

will be accepted)

Mississippi State Department of Health

Revised 12-05-13 Page 2 of 5

Form 261 E

Dietitian Verification of Residency

1. Date: ________________________

2. Name: ________________________________________________________________________________________________

Last

First

Middle

3. Home Address: ________________________________________

4. Telephone Number: (____) _______________

_______________________________________________________________________________________________________

City

State

Zip Code

5. Social Security Number: __________-_______-__________

6. Date of Birth: ______/______/______

7. Documents attached (any two (2) of following) with name and address of applicant

q Telephone Bill

q Bank Statement

FOR PROVISIONAL APPLICANTS ONLY

q Lease

(See STEPS TO LICENSURE)

q Electric Bill

q Gas Bill

q Voter Registration Card

I, the undersigned, do solemnly swear or affirm that I am the above applicant. I have read the above Verification of Residency form, that I am, as of the date of this application a resident of the State of Mississippi, and that all statements contained herein or accompanying this form are true to the best of my knowledge and belief.

____________________________________________________________

Applicant's Signature

Complete form, enclose fee and mail to: Mississippi State Department of Health Professional Licensure: Dietitians Post Office Box 1700 Jackson, Mississippi 39215-1700

Mississippi State Department of Health

Revised 12-05-13 Page 3 of 5

Form 261 E

Dietitian Information/Verification Between States

Instructions: Complete Part I of this form and send to the licensing board of the state or jurisdiction in which you hold a current license. Once they complete Part II, this form should be forwarded to the address on the back of this form. Part I

~ To Be Completed by Applicant ~

To Whom This May Concern:

I am applying for a license as a Dietitian in the State of Mississippi and hereby consent to the release of any information, favorable or otherwise, which you may have concerning my license or my practice. When both (Parts I and II) are completed, please return the form to the licensing authority noted on the back of this form.

Applicant's Signature: ___________________________________________________________________

Date: _______________________

Type or Print Full Name: _________________________________________________________________

First

Middle

Last

Address: ______________________________________________________________________________

Street/Post Office Box

City

State

Zip

Date of Birth: ___________________________ Social Security Number: _________________________

Employer: ______________________________ Supervisor: ___________________________________

Your Job Title: __________________________ Telephone Number: (____) _______________________

Description of License Held in Other Jurisdiction:

Jurisdiction: ____________________________ License Number: ______________________________

Title of License: ________________________________________________________________________

Date Issued: _______________________

Expiration Date: ____________________

Mississippi State Department of Health

Revised 12-05-13 Page 4 of 5

Form 261 E

Part II

Dietitian Information/Verification Between States

~ To Be Completed by State Board ~

1. Does the above information confirm with that in your records? q Yes q No q I no, please explain: ___________________________________________________________________________________

2. Did the applicant obtain the original license from your state? q Yes q No If no, which state issued the original license? __________________________________________________________________

3. Was the applicant licensed under a "grandfathering" provision? q Yes q No 4. Is the applicant a registered Dietitian? q Yes q No 5. Do you consider the applicant to be in good standing at this time? q Yes q No If no, please explain:

___________________________________________________________________________________ 6. According to your records, has the applicant ever been disciplined by your board, any state agency or

by any professional organization? q Yes q No. If yes, please explain and attach a copy of the order, decree or other relevant documentation. ____________________________________________________

7. Do you have any additional comments regarding the applicant's license or practice? ________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Date: _____________

____________________________________________________

Board Chair or Designated Offical

____________________________________________________

Title of Board

____________________________________________________

Address

____________________________________________________

City

State

Zip

Phone

Upon completion of this form by the Licensure/Registration Authority, please forward to: Mississippi State Department of Health Professional Licensure: Dietitian Post Office Box 1700 Jackson, Mississippi 39215-1700

Mississippi State Department of Health

Revised 12-05-13 Page 5 of 5

Form 261 E

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download