Application Form Didactic Program in Nutrition and Dietetics

Family and Consumer Sciences

First Name (required)

Last Name (required)

Phone (required)

�� Email (required)

�� WIN (required)

Your nine-digit �� Identification Number.

Current Address

Street (required)

City (required)

State (required)

Zipcode (required)

Permanent Address

Street

City

State

Zipcode

Courses (required)

Please list all the courses that you are taking this semester.

Honors, Extracurricular Activities (required)

Please list organizations, appointed elected offices, scholarships and any honors received.

Volunteer and Work Experience (required)

Please list any experience, paid or volunteer, that you have had that pertains to the field of dietetics.

Career Goals (required)

State your reasons for selecting dietetics as a career and short- and long-term professional goals

Certify (required)

I hereby certify that the above information is true and correct to the best of my knowledge and belief.

I agree