In making application to the Arkansas Dietetic Licensing Board for the issuance of a license or provisional license as a Dietitian, I have read and agree to abide by the Dietetics Practice Act and the Rules and Regulations of the Arkansas Dietetics Licensing Board. I also agree to complete all application requirements and take all examinations necessary for the processing of my application. Upon issuance of a license, I agree to be bound by the Standard of Professional Responsibility as set forth in the Rules and Regulations. I further understand that the fee submitted with this application is nonrefundable and that the materials submitted for consideration become the property of the Board. I am aware of the schedule of fees and understand that additional fees must be paid to maintain licensure.
I agree to hold the Arkansas Dietetics Licensing Board, its members, its officers, agents, and examiners free from any damage, or claim for damage, or complaint by reason, of any action they, or any one of them may take in connection with this application, the examination (if applicable), the failure of the Board to issue me a license, or any other aspect of licensing. I hereby grant permission to the Board to seek any information or references it deems fit in securing my credentials pertinent to this application.
I further agree that if issued a license, upon the revocation, suspension, or cancellation, or expiration of that license, I shall return the license certificate and license identification to the Board.
The information which I have provided in this application is truthful. I understand that providing false information of any kind may result in the voiding of this application, and my failing to be granted a license or provisional license, or the revocation of my license.