Allied Health Care -Dietician / Nutritionist Supplement Allied Health Care -Dietician : Nutritionist Supplement APP PDF Download Allied Health Care - Dietician / Nutritionist Supplement 1) Name of Applicant: Prefix First Last Suffix 2) Does the applicant have any involvement in food preservation, food science or food chemistry for product development or testing purposes?* Yes No 3) Does the applicant specialize in services to minors with eating disorders?* Yes No 4) Does the applicant provide any food safety or compliance consulting regarding food regulation standards?* Yes No 5) Is the applicant a sales or manufacturer's representative of weight loss drugs, supplements or diets?* Yes No 6) Does the applicant provide referrals for weight reduction surgery including pre-operative and post-operative procedures?* Yes No 7) Does the applicant provide hypnotherapy services as a treatment modality?* Yes No This supplemental application is incorporated into and is deemed a part of the other application(s) submitted in connection with the requested insurance. Any and all notices and representations included in such other application(s) are incorporated by reference in this supplemental application as though fully set forth herein.Producer Name:* Retail Agency Name:* Agent's Signature:*(Required in New Hampshire)PhoneThis field is for validation purposes and should be left unchanged.