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University of North Dakota

Nursing and Professional Disciplines

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Application for Supervised Practice Experience for Community Nutrition Major

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  Personal Information

First Name:   Last Name:   Middle Initial:

  Present address

Street: APT:
City: State:   Zip Code:
Phone Number:
Permanent address the same as the present address?
Yes   No

  Permanent Address

Street: APT:
City: State: Zip Code:

  Email Address

UND E-Mail Address:
Secondary E-Mail Address:

  Eligibility Questions

*Do you have a valid driver's license?
Yes   No

*If accepted into the program, will you be able to provide your own transportation to practicum sites?
Yes   No


*If accepted into the program, will you be able to work a variety of shifts to include early mornings, evenings, and weekends if necessary?
Yes   No


*Have you ever been convicted of a felony?
Yes   No


  Academic Preparation

Please list courses in which you are currently enrolled in the table below.

College/University Course # Course Title Credit Hours
UND Nutr 240 Fundamentals of Nutrition 3


Please list Summer courses in which plan to enroll in the table below.

College/University Course # Course Title Credit Hours
UND Nutr 240 Fundamentals of Nutrition 3

  Acknowledgement and File Upload

*As a condition of this application, I agree that transcripts, grade point averages, and other grade information may be released to the selection committee. By typing your signature, you are agreeing to the above statement:
Signature:



Upload your Cover Letter and Resume below:
Accepted file types are PDF and Word.

Cover Letter:
Resume:



The UND Nutrition & Dietetics Department is authorized to disclose in good faith any information I have provided or that has been provided on my behalf regarding my qualifications and fitness for the Community Nutrition supervised practice experience. By asking the Department to submit this information I am releasing it and its employees from any liability arising from the exchange of this information and any other reasonable and necessary information incidental to the application process.

   
Last Modified 10/15/14