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#0319-RH8501-AC
Supplemental Questionnaire

Last Name
First Name
1
Are you currently registered as a Dietitian with the American Dietetic Association?
Yes No
 

Please provide your registration number and expiration date below:

2

Do you possess a valid California driver's license?

Yes No
 

Candidates must possess and maintain a valid California driver's license.  Provide your valid California driver's license number and expiration date.

3
Describe your experience developing, implementing, and promoting a nutrition program.
4

This recruitment will be used to fill full time and part time vacancies.  Please indicate your preference of referral below:

I am only interested in full time positions at this time
I am only interested in part time positions at this time
I would like to be referred on both full time and part time positions