Dietitians Association of New Brunswick

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Personal Information

Legal Given Name*

First Middle Surname

Name on your official documents (e.g., passport, birth certificate).

Previous Surname(s)*

If applicable, if not please enter N/A.

Do you use the legal name given above ?*

Yes

Please provide the name you use

Date of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

Phone Number*

Alternative Phone Number

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred language for NBAD correspondence*

English

French

Preferred email for NBAD correspondence*

Education - Academic Qualifications

Undergraduate Degree*

Diploma

Institution

Start date (dd/mm/yyyy)

Competition date or anticipated completion date (dd/mm/yyyy)

In progress? (Yes or No)

Post Graduate Degree

Diploma

Institution

Start date (dd/mm/yyyy)

Competition date or anticipated completion date (dd/mm/yyyy)

In progress? (Yes or No)

Other (e.g., special cerification)

Diploma

Institution

Start date (dd/mm/yyyy)

Competition date or anticipated completion date (dd/mm/yyyy)

In progress? (Yes or No)

Education Dietetic Practical Training

Previous Dietetic Practical Training (if applicable)

Name of Accredited Internship/Practicum Program

Rotation/Affiliation Site(s) Location(s)

Dates of Rotation(s)/Affiliation(s)

Current Dietetic Practical Training (request for New Brunswick practical training)*

Name of Accredited Internship/Practicum Program

Name of Internship/Practicum Program Coordinator

Phone number

Address

Rotation/Affiliation Site Coordinator/Mentor Contact Information*

Rotation/Affiliation Site Location

Date of Rotation/Affiliation

Phone number

Address

Previous Registrations with a Dietetic Regulatory Body

Have you previously been registered with NBAD?*

Yes

Please provide your NBAD registration number

Do you currently hold a registration as a Registered Dietitian in another province, territory, state or country?*

Yes

Please complete the following*

Name of organization

Effective date

Expiry date (N/A if active)

Currently working in the jurisdiction? (Yes or No)

Condition or limitations on registration (if applicable)

Have you been registered as a Registered Dietitian in another province, territory, state or country?*

Yes

Please complete the following

Name of Jurisdiction

Year(s) of Registration

Have you ever been refused for registration with a body that is responsible for the regulation of a profession, either within or outside of Canada?*

Yes

Please explain*

Member Contact Directory

NBAD's Member Contact Information Directory for those who wish to participate. This will facilitate sharing of resources amongst members and foster communication. This information will NOT be made available to the public.

I authorize NBAD to share my email address with NBAD members only*

Yes

Please confirm the following*

I shall not sell, exchange or share any of the member contact information from the private directory to/with third parties.*

Mandatory Self-Reporting of Offences

Have any findings or judgments of professional negligence been made against you in any civil or criminal proceedings in New Brunswick, or any other province, territory, state, or country in relation to the practice of dietetics or of any other profession?*

Yes

Have you been charged with or found guilty of an offence under the Criminal Code (Canada), Food and Drugs Act (Canada), the Controlled Drugs and Substances Act (Canada) or the equivalent in any other jurisdiction (within or outside Canada)?*

Yes

Have you been investigated, found guilty or been denied registration due to professional misconduct, incompetence, negligence, or incapacity in New Brunswick, or any other province, territory, state, or country in relation to the practice of dietetics or of any other profession?*

Yes

To your knowledge, are you currently being investigated for professional misconduct, incompetence, negligence, or incapacity in New Brunswick, or any other province, territory, state, or country in relation to the practice of dietetics or of any other profession?*

Yes

Have you been denied registration or currently have conditions or limitations imposed on a registration in New Brunswick, or any other province, territory, state, or country in relation to the practice of dietetics or of any other profession?*

Yes

Please upload any applicable application files

Drop files here or

Accepted file types: pdf, doc, docx, png, jpg, Max. file size: 50 MB.

Front and back copy of your government issued ID,

I affirm that all information recorded on this form is true and accurate. False or misleading statements and omissions or misrepresentations are cause for disqualification.*

Electronic Signature

Date

MM slash DD slash YYYY

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Dietetic Intern Applicants

Application Process

Application Timeline and Fees

Apply for Registration – Dietetic Intern

Personal Information

Education - Academic Qualifications

Education Dietetic Practical Training

Previous Registrations with a Dietetic Regulatory Body

Member Contact Directory

Mandatory Self-Reporting of Offences

Questions?