Section 11-79-12 - Application(a) Applications for licensure as a dietitian shall be submitted to the department on forms provided by the department. An applicant shall provide the following Information: (1) The applicant's legal name;(2) Affirmation that the applicant is beyond the age of majority;(3) The applicant's current residence, business and mailing addresses, and telephone numbers;(4) Current driver's license or State identification card;(5) Current dietetic registration with the Commission on Dietetic Registration;(6) The date and place of any conviction of a criminal offense related to the applicant's possible Performance of the practice of dietetics, unless the conviction has been expunged or annulled, or is otherwise precluded from consideration by section 831-3.1, HRS;(7) Proof that the applicant is a United States Citizen, a United States national, or an alien authorized to work in the United States;(8) Disclosure of similar licensure in any State or territory;(9) Disclosure of disciplinary action by any State or territory against any license held by the applicant; and(10) Any other Information the department may require to investigate the applicant's qualifications for licensure.(b) Failure to provide all of the Information in subsection (a) and payment of required fees shall be grounds to deny the application for licensure.[Eff JAN 24 2008] (Auth: HRS § 448B-3) (Imp: HRS § 436B-10, § 448B-3, § 448B-5)