License Application Forms

Instructions for completing and submitting the forms required for licensure appear below. You may also need to submit additional information (for example, examination scores). Please refer to the license requirements link on the left for complete information regarding all requirements you must meet.

Note: All forms are in Adobe Portable Document Format (PDF). To view or print these documents, you will need to have the free Adobe Reader External Link Icon installed on your computer. Download times and print quality will depend on your connection speed and printer.
Form 1 - Application for Certification ( PDF 39 KB)

Important Notice: A New York State professional license is valid for life unless it is revoked, annulled, or suspended by the Board of Regents. To practice in New York State your professional license must be registered. If your registration has lapsed and you need to reregister, do not submit a Form 1. Instead, contact the Registration and Fees Unit to request a Delayed Registration Application by e-mailing: OPREGFEE@nysed.gov, or by calling 518-474-3817 Ext. 410.  When e-mailing, be sure to include your profession, license number, address on record, new address (if changed), date of birth and the last 4 digits of your SSN.

All applicants for certification must complete this form and submit it with the $294 registration fee directly to the Office of the Professions at the mailing address at the end of Form 1. Make checks payable to the New York State Education Department. NOTE: Your cancelled check is your receipt.
 
You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review. Your signature on Form 1 must be notarized by a Notary Public.

Address/Name Change Form - Optional ( PDF 20 KB)
You are required to notify us within 30 days of any name or address changes. Please read the instructions and complete the appropriate sections of this form.
 

Form 2 - Certification of Professional Education - ( PDF 22 KB)

This form must be submitted directly by the educational institution you attended.
 
  • Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 9 and include any required fee.
  • Section II: The Registrar or appropriate school official must complete this section and return the form in a school envelope directly to the Office of the Professions at the mailing address at the end of the form.

If your program was not registered by the New York State Education Department as qualifying for certification or was not accredited by the Commission on Accreditation for Dietetics Education (CADE) at the time you completed the program, the Registrar must complete Part B. Remind the school that they must attach an official transcript or marksheet showing courses you completed each year and your grades.

NOTE: programs that were "approved" by the CADE must also forward an official transcript and have the Registrar complete Part B.

When studies were completed at more than one school, official records need to be sent to the Office of Professions from each college. Please photocopy the form as needed.

Form 3E - Certification of Dietetics - Nutrition Examination Results - ( PDF 20KB)
This form must be submitted directly by the Certification Board for Nutrition Specialists (CBNS) or the Commission on Dietetic Registration (CDR).
 
  • Section I: Complete this section of the form before sending it to the CBNS or the CDR.
  • Section II: The CBNS or the CDR must complete this section and submit the form directly to:

The New York State Education Department, Office of the Professions
Dietetics and Nutrition Unit
89 Washington Avenue
Albany, NY 12234-1000.

 

Form 4 - Applicant Professional Experience Record (Associate degree applicants only) - ( PDF 20KB)

Applicants with associates degrees must complete and submit this form with the application for certification (Form 1) directly to the Office of the Professions at the mailing address at the end of Form 1. List all of your work experience in dietetics or nutrition. If the work experience is planned work expereince, indicate that in item 5.

Form 4B - Report of Experience Record (Associate Degree applicants only) - ( PDF 24 KB)
Applicants with associate degrees must complete Section I of this form and forward it to the appropriate supervisor for completion of Section II. Your supervisor must complete Section II and submit this form directly to the Office of the Professions at the mailing address at the end of the form. You may photocopy this form as needed to report the total amount of experience required. A Form 4B is not required for the "planned work experience" for which you submit a Form 4C.

Form 4C - Report of Planned Work Experience - ( PDF 24KB)
This form must be submitted directly by the supervisor or internship coordinator.

Complete Section I and forward it to the dietitian or nutritionist who supervised your "planned work experience." Ask your supervisor to complete Section II and submit it directly to the Office of the Professions at the mailing address at the end of Form 4C.

Form 4C should be completed by the internship coordinator at the school if your experience was completed in an internship program.

Form 4E - Endorsement by an Acceptable Dietitian-Nutritionist (Associate Degree applicants only) - ( PDF 17 KB)
Applicants with associate degrees must complete Section I and forward a separate Form 4E to each of the three acceptable dietitians or nutritionists who are endorsing them for certification. Each endorser must complete Section II and submit the form directly to the Office of the Professions at the mailing address at the end of Form 4E.
Last Updated: October 2, 2014