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?*YesNo3) Does the applicant specialize in services to minors with eating disorders?*YesNo4) Does the applicant provide any food safety or compliance consulting regarding food regulation standards?*YesNo5) Is the applicant a sales or manufacturer's representative of weight loss drugs, supplements or diets?*YesNo6) Does the applicant provide referrals for weight reduction surgery including pre-operative and post-operative procedures?*YesNo7) Does the applicant provide hypnotherapy services as a treatment modality?*YesNoThis 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. This iframe contains the logic required to handle Ajax powered Gravity Forms.