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#19-002771-0001
Supplemental Questionnaire

Last Name
First Name
1

Do you possess a current license as a Dietitian/Nutritionist from the Maryland State Board of Dietetic Practice?

Yes No
 

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.

2

Do you possess a current ServSafe Certification?  If yes, please provide the date you were issued the ServSafe Certification. If no, enter N/A.

3

Please describe your experience in the Federal Child Nutrition Program. Please include dates of employment, name(s) of employers, job title and hours worked. If no experience, enter N/A.

4

Do you have experience using the Nutrikids software to analyze menus? If yes, in the box below describe your experience including the name of the employer, dates of employment and hours worked per week performing this task. If you do not have this type of experience, please write N/A.


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