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Coordinated Program in Dietetics Application

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First Name:   Last Name:   Middle Initial:

Present address

City: State:   Zip Code:
Phone Number:
Permanent address the same as the present address? Yes

Permanent Address

City: State: Zip Code:
Phone Number:
UND E-Mail Address:
Secondary E-Mail Address:
Are you the first generation of your family to attend college? Yes   No


Please provide the names and contact information for two individuals completing recommendation forms for you. Request at least one reference from an employer. If you have never worked at paid employment, select an advisor from any substantialvolunteer or service learning experience where you have participated. An academic reference at the university level is also suggested, although faculty members in the UND Department of Nutrition and Dietetics are unable to provide a reference for you. Do not use relatives or personal friends as references.

Reference #1

Name:   Title:
E-Mail Address: Phone Number:
Reference Type: Work-related Academic

Reference #2

Name:   Title:
E-Mail Address: Phone Number:
Reference Type: Work-related Academic


*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 supervised practice sites? Yes   No
Briefly explain, if necessary:

*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
Briefly explain, if necessary:

*If accepted into the program, will there be anything preventing you from working with food or other products to assure acceptability? This includes participation in mealtime, tasting, handling and serving a variety of food items or supplements.
Yes   No
Briefly explain, if necessary:

*If accepted into the program, do you agree to drug testing, if requested? Yes   No

*If accepted into the program, are you willing to complete a criminal background check? Yes   No

*Have you ever been convicted of a felony? Yes   No
If yes, please explain:

*Do you understand that, due to the time restraints that the result from the nature of a coordinated program, there is limited time to hold outside employment while classes are in session? Yes   No
Comment briefly if necessary:

*Do you understand that, due to the rural setting of the UND Coordinated Program in Dietetics, you will be expected to travel distances requiring overnight stays to some supervised practice sites, particularly after the first year in the program? Yes   No
Comment briefly if necessary:


1. Please complete the following in order to clarify your status regarding prerequisites for the coordination program. Note: all professional courses must be completed before beginning the professional phase of the program. You must earn a minimun grade of C (2.0 on 4.0 grade point scale) on all science and nutrition courses. Acceptance into the program will be contingent on successful completion of all prerequisite courses.

2. If you have taken a course at another institution and it has been officially substituted for the listed UND course, enter the course name, number, and place where that course was taken in the Equivalent Course column in place of the UND course.

3. For repeated course, enter the highest grade earned.

4. To calculate grade points, multiply the number of credits x the grade points earned, where A = 4 points; B = 3 points; C = 2 points; D = 1 point, I = Incomplete, S = Satisfactory, U = Unsatisfactory.

5. Do not list additional courses.

6. If you are currently taking a course, list your grade as I for Incomplete.

Equivalent Course Course Title Course # Term & Year Credits Grade Earned Grade Point
Example: Fundamentals of Nutrition Nutr 240 Fall '13 3 B 9
College Composition I Engl 110
Introduction to Psychology Psyc 111
General Chemistry I Chem 121
General Chemistry I Lab Chem 121L
College Algebra Math 103
Composition II Engl 130
Fundamentals of Public Speaking Comm 110
General Chemistry II Chem 122
General Chemistry II Lab Chem 122L
Anatomy for Paramedical Personnel Anat 204
Anatomy Lab Anat 204L
Human Physiology PPT 301
Survey of Organic Chemistry Chem 340
Survey of Organic Chemistry Lab Chem 340L
Introduction to Nutrition & Dietetics N&D 100
Fundamentals of Nutrition Nutr 240
Nutrition Through the Life Cycle N&D 245
World Food Patterns N&D 335
FoodService Safety and Sanitation N&D 220
Principles of Foods and Food Science N&D 260

Upload your resume below:

Cover Letter:
Service Learning Documentation:

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 Coordinated Program in Dietetics. 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. This release also applies to any information provided by persons whose names I have submitted to provide references on my behalf.

Last Modified 10/15/14