Saskatchewan Dietitians Association

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The Saskatchewan Dietitians Association collects the information on this form so that it can process your application and carry out its regulatory mandate under the authority of the Dietitians Act. If you would like more information regarding how SDA uses this information, contact the SDA office at (306) 359 3040 or via email at registrar@saskdietitians.org.

A: General Information

Please type the name you wish you appear on your licence:

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B: Home Address

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C: Current Employment Record

Display forms: 1 2 3 4 5

First Employer

Position/Title
Organization
Start Date
Street/Apartment/Box
City/Town
Province/State
Country
Postal Code
Email
Phone
Status	Full-time Part-time Self-employed
Area of Practice	Administrative Clinical Community Consultant Public Health Other (specify below)
Age Groups	All Ages Adult Pediatric Elderly
Region	Other Athabasca Health Authority Cypress Five Hills Heartland Keewatin Yatthé Kelsey Trail Mamawetan Churchill River Prairie North Prince Albert Parkland Regina Qu'appelle Saskatoon Sun Country Sunrise
Other Details

Second Employer

Position/Title
Organization
Start Date
Street/Apartment/Box
City/Town
Province/State
Country
Postal Code
Email
Phone
Status	Full-time Part-time Self-employed
Area of Practice	Administrative Clinical Community Consultant Public Health Other (specify below)
Age Groups	All Ages Adult Pediatric Elderly
Region	Other Athabasca Health Authority Cypress Five Hills Heartland Keewatin Yatthé Kelsey Trail Mamawetan Churchill River Prairie North Prince Albert Parkland Regina Qu'appelle Saskatoon Sun Country Sunrise
Other Details

Third Employer

Position/Title
Organization
Start Date
Street/Apartment/Box
City/Town
Province/State
Country
Postal Code
Email
Phone
Status	Full-time Part-time Self-employed
Area of Practice	Administrative Clinical Community Consultant Public Health Other (specify below)
Age Groups	All Ages Adult Pediatric Elderly
Region	Other Athabasca Health Authority Cypress Five Hills Heartland Keewatin Yatthé Kelsey Trail Mamawetan Churchill River Prairie North Prince Albert Parkland Regina Qu'appelle Saskatoon Sun Country Sunrise
Other Details

Fourth Employer

Position/Title
Organization
Start Date
Street/Apartment/Box
City/Town
Province/State
Country
Postal Code
Email
Phone
Status	Full-time Part-time Self-employed
Area of Practice	Administrative Clinical Community Consultant Public Health Other (specify below)
Age Groups	All Ages Adult Pediatric Elderly
Region	Other Athabasca Health Authority Cypress Five Hills Heartland Keewatin Yatthé Kelsey Trail Mamawetan Churchill River Prairie North Prince Albert Parkland Regina Qu'appelle Saskatoon Sun Country Sunrise
Other Details

Fifth Employer

Position/Title
Organization
Start Date
Street/Apartment/Box
City/Town
Province/State
Country
Postal Code
Email
Phone
Status	Full-time Part-time Self-employed
Area of Practice	Administrative Clinical Community Consultant Public Health Other (specify below)
Age Groups	All Ages Adult Pediatric Elderly
Region	Other Athabasca Health Authority Cypress Five Hills Heartland Keewatin Yatthé Kelsey Trail Mamawetan Churchill River Prairie North Prince Albert Parkland Regina Qu'appelle Saskatoon Sun Country Sunrise
Other Details

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D: Academic Qualifications

Have you requested an official transcript of all pertinent courses (with all final grades) sent directly from the University?

Yes No

Have you requested an official transcript from the Dietetic Regulatory Body?

Yes No

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E: Practical Training

Accredited Dietetic Internship Program

Pre-Approved Practicum Program

Have you requested a letter of verification from the Institution?

Yes No

Have you requested a letter of verification from the Dietetic Regulatory Body?

Yes No

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F: Good Standing & Professional Conduct

1. Have you ever been found guilty of an offence pursuant to the Criminal Code, the Narcotic Control Act, the Controlled Drugs and Substances Act or the Food and Drug Act?
   
   Yes No
   
   
2. Have you been found guilty of professional misconduct, incompetence or negligence in Saskatchewan or any other jurisdiction in relation to the practice of diatetic or any other profession?
   
   Yes No
   
   
3. Are you the subject of any current proceedings for misconduct, incompetence or negligence?
   
   Yes No
   
   

   If you have answered "yes" to ANY OF THE ABOVE QUESTIONS, please provide details.

   
   
   
4. Have you been previously registered with the Saskatchewan Dietitians Association?
   
   Yes No
   
   If you have answered "yes", please provide the following information.
   
   

   Date of Previous Registration
   Licence Number

   
   
   
5. Are you presently registered in any other jurisdiction related to the practice of dietetics?
   
   Yes No
   
   If you have answered "yes", please provide the following information.
   
   

   Dietitians of Canada #
   Provincial Association	— AB BC MB NB NL NS NT NU ON PE QC SK YT #
   American #
   International	#

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G: Licence and Registration

Type of Licence

1. Full Practicing Licence
2. Restricted Licence

Canadian Dietetic Registration Examination (CDRE)

Have you previous written the CDRE registration examination?

Yes No

If so, please provide the following information:

Result
Date of Examination

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H: Miscellaneous

I agree to have my contact information added to the SDA Roster published on the "Members Only" section of the website.

Yes No

My prefered place to receive email from SDA is:

Home Work

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I: Login Information

Please enter your preferred username and password.

By submitting this form electronically, I agree to the following terms:

I verify that all statements contained in this application are accurate. I understand that a false or misleading statement or misrepresentation may be cause for revocation of my Membership.

I agree to notify the SDA Board within 30 days when there are any changes to the information contained within this form.

If I am a member of another regulatory body, I agree to have the Registrar obtain verification of my membership in good standing and obtain any documents required.

I understand and accept these terms.