HURLEY MEDICAL CENTER
DEPARTMENT OF NUTRITION SERVICES
FORM C
1. Have you previously applied to a dietetic internship program?_________ If yes, how many
times have you previously applied?______________Which programs did you previously
apply to (in order from first to last, including the year(s) you applied)?
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2. Have you previously been accepted in/or enrolled in a dietetic internship program?_________
If yes, why were you unable to complete the program?
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I certify that the information that I have provided in this application is true and accurate and
recognize that any false or incorrect statements made herein will be grounds for my dismissal
from the program.
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Signature
DS 10/11
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Date