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Form 4C - Report of Planned Work Experience

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.