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SECTIONS TO BE COMPLETED FOR ALL APPLICATION TYPES (Go to the
Nevada Statutes and Nevada Administrative Code
link (Click on Link) to find links to the Nevada Revised Statutes (NRS’s) listed in this application.)
Application Attestations (Must check first 2 boxes, check last 2 boxes only if they apply)
☐I certify that I am of good moral character.
☐I am aware of the mandatory abuse reporting requirements pursuant to NRS 200.5093, NRS 200.50935, and
NRS 432B.220.
☐I certify that I am at least 21 years of age. (If you are not 21 see Provisional License Applicants section)
☐If you do not provide a method of electronic communication, such as an e-mail address or any other method by which
to communicate with you other than by telephone or U.S. mail, you must check this box attesting that this is not
feasible and acknowledging that the U.S. mail is the only means which to communicate with you.
Child Support Information: (Must check one box)
☐I am not subject to a court order for the support of a child.
☐I am subject to a court order for the support of one or more children and am in compliance with the order or with a
plan approved by the district attorney or other public agency enforcing the order for repayment of the amount owed
pursuant to the order.
☐I am subject to a court order for the support of one or more children and I am not in compliance with the order or a
plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount
owed pursuant to the order. You are required to contact the district attorney or other public agency enforcing the
order to determine the actions that you may take to satisfy the arrearage.
In accordance with NRS 425.520, your application will be denied if you do not indicate which of the provisions above
applies to you.
Disciplinary Action (Must check one box)
Are you now, or have you ever been, the subject of any disciplinary action by the Commission on Dietetic Registration of
the Academy of Nutrition and Dietetics?
☐Yes ☐ No ☐ N/A (only check N/A if you are not or have never been registered with the CDR) If yes, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Criminal History (Both boxes must be checked if true)
☐I attest that I have never been convicted of any of the following crimes:
• Murder, voluntary manslaughter or mayhem;
• Assault with intent to kill or to commit sexual assault or mayhem;
• Sexual assault, statutory sexual seduction, incest, lewdness or indecent exposure, or any other sexually related
crime that is punished as a felony;
• A crime involving domestic violence that is punished as a felony;
• Abuse or neglect of a child or contributory delinquency
• Abuse, neglect, exploitation or isolation of older persons or vulnerable persons, including, without limitation, a
violation of any provision of NRS 200.5091 to NRS 200.50995, inclusive, or a law of any other jurisdiction that
prohibits the same or similar conduct;
• A violation of any provision of NRS 422.450 to NRS 422.590, inclusive; or
• Any other felony involving the use or threatened use of force or violence against the victim or the use of a
firearm or other deadly weapon.
