Directory listings are posted for 12 months following submission. Is this a new listing or a renewal?New or Renew*If renewing with changes, you only need to complete the fields you would like to have changed in your listing. New Listing Renewal Listing - No Changes Renewal Listing - With Changes Referral Directory Listing InformationRD/RDN or Organization's Name* Photo (If Desired)Accepted file types: jpg, png, Max. file size: 2 MB.PhoneEmail Website Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Services ProvidedPopulations ServedDescribe Referral RequirementsAre self referrals accepted? Are patients/clients required to be referred by a provider or become established with a provider in your office? Translation Services Available (list languages and if they are telephonic/in-person) Information for KAND Board Use OnlyThe KAND Board of Directors reserves the right to review all Referral Directory listings for approval. A full refund will be issued if the Board decides that an individual or organization will not be listed. Please list the name, credentials and CDR registration number of individuals providing nutrition counseling at your organization.*This response will be used to verify that a licensed, registered dietitian is on staff. First NameLast NameCredentials (RD, LDN, etc.)CDR Registration Number Directory Listing Type*Listings will be posted for approximately one year and can be renewed on an annual basis. Individual Consultant - One RD/RDN Corporate or Organization - One or Multiple RD/RDNs Total $0.00 Credit CardCard Details Cardholder Name Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Confirmation of Payment Email*Please list the email address where you would like to receive a confirmation of payment. Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Δ
