Wyoming Dietetics Licensing Board 2001 Capitol Avenue, Room 104 Cheyenne WY 82002 2016-2018 LATE RENEWAL NOTICE In order for your license to remain current you must renew by June 30, 2016. ($225.00 fee)

APPLICATION The Board requires receipt of the complete, original signed renewal application; therefore, faxed and incomplete applications are unacceptable. The renewal fee of $225.00 (nonrefundable) made payable to the State of Wyoming must be mailed with the application. CONTINUING EDUCATION Dietitians licensed in the State are required to maintain 30 hours of continuing education every two (2) years. Please provide the information requested below and attach verification for proof of attendance indicating approved hours to this form. Refer to Chapter 6, Section 1 of your current copy of the Rules and Regulations for specific continuing education requirements and Section 2 for exemptions to the continuing education requirement for licensure renewal. CDR VERIFICATION Dietitians licensed in the State are required to maintain current registration with CDR. Please provide verification of a current registration with CDR.

If you will not be renewing your license to practice in the State of Wyoming, please inform the Board in writing at the above address or by email to [email protected].

Wyoming Dietetics Licensing Board 2001 Capitol Avenue, Room 103 Cheyenne WY 82002 2016-18 DIETETICS RENEWAL APPLICATION Please type or print neatly.

1. Applicant Information Last Name

First Name

Middle Initial

Previous Names Used

2. Home Address Home Address

City

Home Phone

Cell Phone

State

Zip

State

Zip

State

Zip

3. Business Address WYOMING Business Address

City

Business Phone

Business Fax

OTHER Business Address

City

Business Phone

Business Fax

4. Correspondence from Board Office I prefer to receive mail at my: 

Home



Email address is:

Business

5. CDR Certification I hold and have requested that the Board receive verification of my:



CDR Certification: Certificate Number: _______________________ Expiration Date: ______________

5. Continuing Education To show completion of the required thirty (30) hours of continuing education, please itemize your continuing education below and attach copies of your certificates. Incomplete charts will be returned. DATE(S)

PRESENTER

COURSE/ACTIVITY

PROGRAM SPONSOR

A B E F

TOTAL HOURS SUBMITTED:

HOURS

6. Practice History If you mark yes to any of the below questions, you must attach a detailed explanation. Provide copies of documentation if applicable.

a. Within the last five (5) years have you ever had any application for licensure or certification refused, dismissed, denied, or withdrawn by any professional licensing authority? b. Within the last five (5) years have you ever allowed any professional license to lapse in lieu of disciplinary action, or had a limited, conditioned, restricted, or probationary license issued by any licensing authority? c. Within the last five (5) years have you had a professional license revoked, voluntarily surrendered, suspended, reprimanded, censured, conditioned, restricted, or otherwise disciplined? d. Within the last five (5) years, have any unresolved or pending complaints ever been filed against you with any licensing agency or association? e. Is there any disciplinary action pending against you by any licensing authority or any state drug enforcement authority? If YES, where and when? f. Within the last five (5) years have you ever been charged or convicted (including a nolo contendere plea or guilty plea) of a misdemeanor, felony, or other criminal offense (other than minor traffic violations) in any state or federal court? If YES, in addition to the affidavit, attach a certified copy of the court records regarding your conviction, the nature of the offense date of discharge, if applicable, as well as a statement from the probation or parole officer. g. Are you currently addicted to or abusing any chemical substance including alcohol (excluding tobacco and caffeine) that would impair your ability to practice? h. Do you currently have or have you been previously diagnosed with any condition or impairment (including but not limited to, substance abuse, alcohol abuse, or a mental, emotional or nervous disorder, or condition) that in any way affects your ability to practice in a competent, ethical, and professional manner? i. Within the last five (5) years, have you been named as a defendant to a civil suit related to your practice or profession (i.e. malpractice, Medical Review Panel)?

 Yes  No

 Yes  No

 Yes  No  Yes  No  Yes  No

 Yes  No

 Yes  No

 Yes  No

 Yes  No

10. Warning, Agreement, and Affidavit By signing this application:

I understand that making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment for not more than two (2) years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. § 6-5-303.) I do hereby state that I have read, understand, and agree to abide by the rules and regulations promulgated by the Dietetics Licensing Board, and W.S. § 33-47-101 through 110. I also agree to adhere to the codes of ethics applicable to my profession and this application. I verify that I am the person making the foregoing statements and that they are made in good faith and are true in every respect.

SIGNATURE

DATE