rn-en
Content
INSTRUCTION SHEET
REGISTERED NURSE
Examination
Endorsement
Restoration
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
In accordance with the Illinois Nurse Practice Act, "For the protection of life and the promotion of health, and the prevention of illness and communicable diseases, any person practicing or offering to practice professional and practical
nursing in Illinois shall submit evidence that he or she is qualified to practice, and shall be licensed as hereinafter provided." A copy of the Illinois Nurse Practice Act and the Rules can be downloaded from the IDFPR Web Site at www.
idfpr.com. If you are issued a registered nurse license, please be advised that your license will expire on May 31st of
every even-numbered year.
Table of Contents
Page
Applying for Licensure ..............................................................................2
General Instructions ..............................................................................2
Examination
...........................................................................................2
General Examination Instructions .........................................................2
Practice Pending Licensure ...................................................................3
Practice Under Supervision ...................................................................3
Educated Inside U.S. or one of its Territories .......................................3
Educated Outside U.S. or one of its Territories .....................................4
Endorsement
...........................................................................................5
General Endorsement Instructions ........................................................5
Temporary Permit ..................................................................................6
Educated Inside U.S. or one of its Territories .......................................6
Educated Outside U.S. or one of its Territories .....................................7
Restoration
...........................................................................................8
General Restoration Instructions ...........................................................8
Temporary Permit ..................................................................................9
Forms Completion Guide ................................................................. 10-11
Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.com.
DPR-RN Instructions Revised 3/15
Packet updated 5/15/15
APPLYING FOR LICENSURE
General Instructions
1. Apply Directly On-Line. Register for the examination by referring to the
Continental Testing Web site (www.continentaltesting.net) for information
on how to apply for the examination on-line and pay the test fee by credit
card. If you are licensed in another U.S. jurisdiction based on passage of
the national licensing examination, you are not an "examination" applicant.
2. Read these instructions, then read the Filing Instructions related to the method
of application under which you qualify to determine the documentation and
forms you must submit. The methods under which you may file to obtain a
license as a registered nurse are:
a. Examination
b. Endorsement
c. Restoration
3. All individuals applying for initial licensure and/or restoration as a registered
nurse in Illinois must submit to a criminal background check and provide
evidence of fingerprint processing from the Illinois State Police, or its
designated agent. See attached "Important Notice--Criminal Background
Check Requirement" for more information concerning this requirement.
Note: The Criminal Background Check Requirement does not apply to
those applicants making application for registered nurse examination/
licensure who are licensed in Illinois as a licensed practical nurse.
4. All documents in a foreign language must be accompanied by an original,
notarized translation that has been transcribed by a person other than the
applicant, who is fluent in both English and the language of the documents(s).
The translator shall certify to the above requirements as well as to the accuracy of the translation.
5. For information concerning the completion of any of the enclosed forms,
refer to the Forms Completion Guide on pages 10 and 11. You may photocopy any of the enclosed forms if additional forms are needed.
6. If needed, a telephone number for assistance in completing the Application
Package is indicated on the REFERENCE SHEET.
EXAMINATION
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
General Examination
Instructions
1. Read the above General Instructions before proceeding. All documents and
forms required for licensure by examination must be submitted to:
Continental Testing Services Inc.
P.O. Box 100
LaGrange, Illinois 60525-0100
2. Application fee payment must be in the form of a certified check or money
order made payable to Continental Testing Services, Inc. A separate examination registration fee will be paid at the actual time of registration as noted
in Chart II on the Reference Sheet. To determine the fees, see the Reference
Sheet, Chart I and II.
Registered Nurse - Page 2
EXAMINATION (cont'd)
General Examination
Instructions (cont'd)
3. Conditions of Application--Applicants have three years from the date of the
Department's receipt of the application to complete the application process
including passage of examination. If the process has not been completed in
three years, the application shall be denied, the fee forfeited, and the applicant
must reapply and meet the requirements in effect at the time of application,
including proof of the successful completion of at least 2 additional years
of professional nursing education.
NOTE: Excelsior College is an unapproved nursing education program
in the State of Illinois due to the fact that it does not have concurrent theory
and clinical components as required by the Illinois Nurse Practice Act.
Therefore, it is considered to be a correspondence course which is identified
by the Act as not meeting the requirements for licensure.
Practice Pending
Licensure
Pursuant to Public Act 95-0639, you are prohibited from practicing until such
time as you have completed and passed the Department approved licensure
examination and are in receipt of official IDFPR/CTS notification.
Practice Under
Supervision
Pursuant to 60-10(d)(e) of the Illinois Nurse Practice Act, an applicant may
practice as a license-pending registered nurse under direct supervision for a
period of three months from the official date of passing the licensure exam as
inscribed within his/her official formal pass letter. No applicant for licensure
practice under the provisions of this paragraph shall practice license-pending
except under the direction of a registered professional nurse or an advanced
practice nurse licensed under this Act. In no instance shall any such applicant
practice or be employed in any management capacity.
Educated Inside the U.S. or
one of its Territories
If you received your education in the United States or one of its territories, you
must submit the following documentation (read the General Instructions and
the General Examination Instructions on page 2 now, if you have not already
done so):
- IMPORTANT NOTICE -
The National Council of State Boards of
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing
who licensure participate in Nursys®.
Please visit Nursys.com (www.nursys.
com) or https://www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to
view a complete list.
If the state(s) where you have been licensed
as a nurse licensure participates in Nursys®,
you must request verification of your licensure
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does
not appear on the Nursys® list of licensure
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the
Illinois Board of Nursing.
a. Application for Licensure and/or Examination (four-page);
b. CT-NUR Form (Verification of Licensing Agency/Board)--Submit a verification
of licensure from the state of original licensure, current state of licensure, and
any jurisdiction in which you have actively practiced within the last 5 years.
Verification of licensure for an LPN license held in another jurisdiction within
the last 5 years will only be required if you were not subsequently licensed in
the same jurisdiction as an RN.
You must direct the appropriate licensing agency(s)/board(s) to return the
completed form directly to you to be submitted with your application.
c.
ED-NUR Form (Certificate of Education)--Form must be signed by the
Dean or Director of your nursing education program with school seal
affixed, indicating graduation from a professional nursing education program approved by the Department or have been granted a certificate of
completion of pre-licensure requirements from another U.S. jurisdiction,
OR submission of official transcripts with school seal affixed.
d. Fee--See page 2, General Examination Instructions, paragraph 2.
Registered Nurse - Page 3
EXAMINATION (cont'd)
Educated Outside the U.S.
or one of its Territories
In order to be considered for licensure, applicants who received their education
outside the United States or one of its territories must submit the following (read
the General Instructions and the General Examination Instructions on page 2 now,
if you have not yet done so):
a.
- IMPORTANT NOTICE -
Supporting Document CCA must be completed and submitted with each application. Your application will not be processed without completion of this form.
b. Application for Licensure and/or Examination (four page);
The National Council of State Boards of
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing
who licensure participate in Nursys®.
Please visit Nursys.com (www.nursys.
com) or https://www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to
view a complete list.
If the state(s) where you have been licensed
as a nurse licensure participates in Nursys®,
you must request verification of your licensure
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does
not appear on the Nursys® list of licensure
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the
Illinois Board of Nursing.
c.
CT-NUR Form (Verification of Licensing Agency/Board)--Submit a verification
of licensure from the state of original licensure, current state of licensure and
any jurisdiction in which you have actively practiced within the last 5 years.
Verification of licensure for an LPN license held in another jurisdiction within
the last 5 years will only be required if you were not subsequently licensed in
the same jurisdiction as an RN;
You must direct the appropriate licensing agency(s)/board(s) to return the completed form directly to you to be submitted with your application.
d. Submit the following proof of education:
1. A credentials evaluation report of your foreign nursing education from a
Department approved credentialing service. One such service is the Commission on Graduates of Foreign Nursing Schools (CGFNS) Credentials
Evaluation Service (CES). The required report is the Healthcare Profession & Science Course-by-Course Report. The Division will download
the credentials evaluation report from CGFNS' Web site when it becomes
available.
You may contact CGFNS Credentials Evaluation Service as follows:
Credentials Evaluation Service
CGFNS/ICHP
3600 Market Street, Suite 400
Philadelphia, PA 19104-2651
Telephone #215/349-8767
Web site: http://www.cgfns.org
Additionally, the Educational Records Evaluation Service (ERES) has been
approved by the Division as a nursing educational credentialing agency. The
required report to request is the Nursing Evaluation and Course by Course
Report. The report will be downloaded from ERES when available.
You may contact ERES as follows:
- NOTE Proof of licensure in your
country of
education shall be
required as a part of the
credentialing process.
Educational Records Evaluation Service, Inc.
601 University Avenue, Suite 127
Sacramento, CA 95825
Telephone # 916/921-0790
Email: [email protected]
Web site: http://www.eres.com
Further, if your first language is not English, you shall be required to submit certification of passage of the Test of English as a Foreign Language
(TOEFL). The minimum passing score on the paper-based test is 560. The
minimum passing score on the computer-based test is 220. The minimum
passing score on the internet-based test is 83.
Registered Nurse - Page 4
EXAMINATION (cont'd)
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
Education Outside the U.S. or one
of its Territories (cont'd)
TOEFL scores previously considered as "passing" scores will be accepted
for a period of two years from the date of passage.
e.
In lieu of the above, the educational requirement may be met by submission of
proof issuance of the following original certificates from the Commission on
Graduates of Foreign Nursing Schools (CGFNS):
CGFNS Certificate
VisaScreen Program Certificate
f.
Fee--See page 2, General Examination Instructions, paragraph 2.
ENDORSEMENT
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
General Endorsement
Instruction
1. Read the Applying for Licensure, General Instructions on page 2 be
fore proceeding. All documents and forms required for licensure
by endorsement must be submitted as a packet to:
Illinois Department of Financial and Professional Regulation
ATTN: Division of Professional Regulation
P.O. Box 7007
Springfield, IL 62791
2. Fee payment must be in the form of a check or money order made
payable to Department of Financial and Professional Regulation (see
Reference Sheet, Chart I).
NOTE: Excelsior College is an unapproved nursing education program in
the State of Illinois due to the fact that it does not have concurrent theory and
clinical components as required by the Illinois Nurse Practice Act. Therefore,
it is considered to be a correspondence course which is identified by the Act as
not meeting the requirements for licensure.
There is a provision in the Act to allow for individual review of applications
from applicants who are graduates of such programs provided the applicant is
currently licensed in another U.S. jurisdiction and has been actively practicing
in clinical nursing for a minimum of two (2) years. The applicant must have an
employer complete a VE (Verification of Employment) form verifying two full
years of clinical practice as a registered nurse. This must be submitted with
the endorsement application. When the application is complete, it is reviewed
by the Board of Nursing for a determination of eligibility to be rendered.
Registered Nurse - Page 5
ENDORSEMENT (cont'd)
Temporary Permit
In accordance with Section 60-10(f)(g) of the Illinois Nurse Practice Act, you may be eligible
to receive a temporary permit. The permit is valid for six months from the date of issuance, or
issuance of an Illinois Registered Nurse License, or notification that the Department intends to
deny licensure, whichever comes first. It will be your responsibility to complete the endorsement licensure process prior to the expiration of the temporary permit. In order to receive
the permit, submit the following forms and documentation (read the General Instructions on
Page 2 and the General Endorsement Instructions above now, if you have not yet done so):
a.
Supporting Document CCA must be completed and submitted with each
application. Your application will not be processed without completion of this
form.
- Important Notice -
b.
Application for Licensure and/or Examination (four page);
Applicants educated outside
the U.S. or its Territories must
have an acceptable credentials
evaluation report from a
Department-approved
credentials evaluation service
on file with the Department
indicating their nursing
education is comparable to an
entry-level registered
professional nursing education
program in the United States
prior to being deemed eligible
for a temporary permit.
c.
TP-NUR Form (Temporary Permit);
d.
Photostatic copies of all current active Registered/Licensed Practical Nurse licenses and/
or temporary permits/licenses held by you in any other jurisdiction(s) of the United States.
Current licensure in at least one other jurisdiction of the United States is required by
the Illinois Nursing and Advanced Practice Nursing Act;
e.
Fee--Combine the endorsement fee and the temporary permit fee into one check or
money order. (See page 5, General Endorsement Instructions, paragraph 2, for additional
information.)
f.
Proof of fingerprint submission in the form of a copy of the fingerprint receipt (for Illinois
graduates or Illinois residents), or a completed FP-NUR form for out-of-state and foreigneducated applicants.
Educated Inside U.S. or
one of its Territories
In order to be considered for licensure, applicants who were educated in the United States or
one of its territories must submit the following: (read the General Instructions on Page 2 and
the General Endorsement Instructions on page 5 now, if you have not yet done so):
a.
Supporting Document CCA must be completed and submitted with each
application. Your application will not be processed without completion of this
form.
b.
Application for Licensure and/or Examination (four page). You need not resubmit this
form if you previously applied for a temporary endorsement permit;
c.
CT-NUR Form (Verification of Licensing Agency/Board--Submit verification of licensure
from the state of original licensure, current state of licensure and any jurisdiction in which
you have actively practiced within the last 5 years. Verification of licensure for an LPN
license held in another jurisdiction within the last 5 years will only be required if you
were not subsequently licensed in the same jurisdiction as an RN. Current registration in
another state is required by the Illinois Nurse Practice Act. You must direct the licensing
agency/board to return the completed form to you to be submitted with your application.
d.
ED-NUR Form (Certificate of Education) indicating graduation from a professional nursing
education program approved by the Department; or the granting of a certificate of completion of pre-licensure requirements from another U.S. jurisdiction. The ED form must
be signed by the director of the nursing education program with the school seal affixed,
- IMPORTANT NOTICE CERTIFICATION OF LICENSURE
The National Council of State Boards of
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing
who licensure participate in Nursys®.
Please visit Nursys.com (www.nursys.
com) or https://www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to
view a complete list.
If the state(s) where you have been licensed
as a nurse licensure participates in Nursys®,
you must request verification of your licensure
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does
not appear on the Nursys® list of licensure
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the
Illinois Board of Nursing.
OR official transcripts with school seal affixed.
e.
Fee--See General Endorsement Instructions, page 5, paragraph 2.
Registered Nurse - Page 6
ENDORSEMENT (cont'd)
Educated Outside U.S. or
its Territories
- IMPORTANT NOTICE -
In order to be considered for licensure, applicants who were educated outside the United
States or one of its territories must submit the following (read the General Instructions
on Page 2 and the General Endorsement Instructions on page 5 now, if you have not
yet done so):
a.
Application for Licensure and/or Examination (four page). You need not submit
this form if you previously applied for a temporary endorsement permit;
b.
Supporting Document CCA must be completed and submitted with each application.
Your application will not be processed without completion of this form.
c.
CT-NUR Form (Verification of Licensing Agency/Board)--Submit verification
of licensure from the state of original licensure, current state of licensure and any
jurisdiction in which you have actively practiced within the last 5 years. Current
registration in another state is required by the Illinois Nursing and Advanced Practice
Nursing Act. Verification of licensure for an LPN license held in another jurisdiction
within the last 5 years will only be required if you were not subsequently licensed
in the same jurisdiction as an RN.
CERTIFICATION OF LICENSURE
The National Council of State Boards of
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing
who licensure participate in Nursys®.
Please visit Nursys.com (www.nursys.
com) or https://www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to
view a complete list.
If the state(s) where you have been licensed
as a nurse licensure participates in Nursys®,
you must request verification of your licensure
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does
not appear on the Nursys® list of licensure
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the
Illinois Board of Nursing.
You must direct the licensing agency/board to return the completed form to you to
be submitted with your application.
d.
Request the following proof of education to be prepared for and make available to
the Department:
1. A credentials evaluation report of your foreign nursing education from
a Department approved credentialing service. The credentials evaluation
report must reflect proof of licensure in the country of education. One
such service is the Commission on Graduates of Foreign Nursing Schools
(CGFNS) Credentials Evaluation Service (CES). The required report is
the Healthcare Profession & Science Course-by-Course Report. The Division
will download the credentials evaluation report from CGFNS' Web site when it
becomes available.
You may contact CGFNS Credentials Evaluation Service as follows:
Credentials Evaluation Service
CGFNS/ICHP
3600 Market Street, Suite 400
Philadelphia, PA 19104-2651
Telephone # 215/349-8767
Web site: http://www.cgfns.org
- NOTE Proof of licensure in your
country of
education shall be
required as a part of the
credentialing process.
Additionally, the Educational Records Evaluation service (ERES) has been approved
by the Division as a nursing educational credentialing agency. The required report
to request is the Nursing Evaluation and Course by Course Report. The report will
be downloaded from ERES when available.
You may contact ERES as follows:
Educational Records Evaluation Service, Inc.
601 University Avenue, Suite 127
Sacramento, CA 95825
Telephone # 916/921-0790
Email: [email protected]
Web site: http://www.eres.com
Registered Nurse - Page 7
ENDORSEMENT (cont'd)
Educated Outside U.S. or
its Territories (cont'd)
Further, if your first language is not English, you shall be required to submit certification of passage of the Test of English as a Foreign Language
(TOEFL). The minimum passing score on the paper-based test is 560. The
minimum passing score on the computer-based test is 220. The minimum
passing score on the Inter-based test is 83.
TOEFL scores previously considered as "passing" scores will be accepted
for a period of two years from the date of passage.
e. In lieu of the above, the educational requirement may be met by submission
of proof issuance of the following original certificates from the Commission
on Graduates of Foreign Nursing Schools (CGFNS):
f.
CGFNS Certificate
VisaScreen Program Certificate
Fee--See page 5, General Endorsement Instructions, paragraph 2.
RESTORATION
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
General Restoration
Instructions
Do the following if you wish to apply for the restoration of your license because
it has expired or been placed on inactive status for more than five years. Read
the General Instructions on Page 2 before proceeding. All documents and forms
required for licensure by restoration must be submitted to the following address:
Illinois Department of Financial and Professional Regulation
ATTN: Division of Professional Regulation
P.O. Box 7007
Springfield, Illinois 62791
Fee payment must be in the form of a check or money order made payable to
the Department of Financial and Professional Regulation. (See the Official Use
Only Box on supporting document RS (Restoration), for the fee amount you
must submit.)
Submit the following documents and/or forms:
a. Application for Licensure and/or Examination (four page);
b. Supporting Document CCA must be completed and submitted with each
application. Your application will not be processed without completion of
this form.
c. RS Form (Restoration)--If this form was not included in the application
packet, you must obtain one by contacting the Department of Financial and
Professional Regulation at 1-800-560-6420;
Registered Nurse - Page 8
RESTORATION
General Restoration
Instructions (cont'd)
~IMPORTANT NOTICE~
These Restoration
Instructions apply only to
those registered nurses whose
licenses have been on inactive
status, or in non-renewed
status, for five or more years.
If your license has been
inactive, or in non-renewed
status, for less than five
years, you should contact
the Department of Financial
and Professional Regulation
at 1-800-560-6420 for detailed
instructions on how to
restore it to active status.
Temporary Permit
(cont'd)
d. CT-NUR Form (Verification of Licensing Agency/Board)--Submit verification
of licensure from the state of original licensure, current state of licensure and
any jurisdiction in which you have actively practiced within the last 5 years.
Verification of licensure for an LPN license held in another jurisdiction within
the last 5 years will only be required if you were not subsequently licensed
in the same jurisdiction as an RN.You must direct the licensing agency/board
to return the completed form to you to be submitted with your application.
e. VE Form (Verification of Employment/Experience)--This form must be completed by the Personnel Representative for Nursing Services of your place of
employment and returned to the Department of Financial and Professional
Regulation, Division of Professional Regulation in a sealed envelope.
f.
DD214--If restoring after active military service, submit a copy of this form.
NOTE: If unable to provide proof of fitness to practice nursing via submission
of a VE form substantiating active engagement in nursing practice in
another U.S. jurisdiction within the last five (5) years, persons making
application for restoration of license shall be required to successfully
complete the Department-approved licensure examination (NCLEX)
prior to the restoration of their license. You must apply directly to the
Department; information to facilitate the exam process will be provided
once the application has been reviewed and evaluated by the Department.
In accordance with Section 60-25(b)(e) of the Illinois Nurse Practice Act, you
may apply for a temporary permit. The permit is valid for six (6) months from
the date of issuance, or re-issuance of a permanent license by restoration or notification that the Department intends to deny licensure, whichever comes first.
It will be your responsibility to complete the restoration process prior to the
expiration of the temporary permit. If eligible, the permit will be issued within
fourteen days of receipt of a complete application.
In order to receive the permit, submit the following forms and documentation:
a.
Application for Licensure and/or Examination (four page);
a.
Supporting Document CCA must be completed and submitted with each
application. Your application will not be processed without completion of
this form.
b.
TP-NUR form (Temporary Permit);
c.
Photostatic copies of all current active Registered/Licensed Practical
Nurse licenses and/or temporary permits/licenses held by you in any other
U.S. jurisdiction(s). Current licensure in at least one other jurisdiction of
the United States is required by the Illinois Nurse Practice Act, or
verification of employment in nursing practice within the last five years in
a United States jurisdiction;
d.
Fee--Combine the restoration fee and the temporary permit fee into one
check or money order.
Registered Nurse - Page 9
FORMS COMPLETION GUIDE
This guide will help you complete the forms needed to apply for licensure. For specific information regarding the forms
which you will be required to submit, refer to the filing instructions relative to the method of licensure under which you
are applying.
Application for Licensure
and/or Examination
Provide all applicable information requested on all four pages of the application.
The following will assist you in this endeavor.
1. Part 1--Use the Reference Sheet (Chart I) to record the appropriate Profession Name, 3 digit Profession Code, Licensure Method and Fee;
2. Part II--Enter all applicable information requested. On number 3, Social
Security Number is mandatory;
3. Part III, number 6--Itemize all university/college coursework, including
nursing education since graduation from high school. Please indicate beginning and ending dates by year;
4. Part IV--Record of Licensure Information. Individuals licensed in a U.S.
jurisdiction or a foreign country or province must state whether or not they
have ever held licensure (either permanent or temporary) to practice as a
registered nurse or licensed practical nurse;
5. Part V--You must indicate type, dates, and results for any and all nurse
examinations taken (i.e., NCLEX-RN);
6. Part VI--This part must be completed by all applicants;
7. Part VII--Graduates of Illinois Nursing Education Programs must indicate
school code in item "c." (See Reference Sheet, Chart IV.) All other applicants indicate "See ED-NUR" in the space provided for school code;
8. Part VIII--This part must be completed by all applicants;
9. Part IX--Read the certifying statement and then sign and date your application.
Registered Nurse - Page 10
FORMS COMPLETION GUIDE (cont'd)
CCA
Health Care Workers Charged
With Or Convicted Of Criminal
Acts
This Document MUST be completed and submitted with each application. Your application will not be processed without completion/receipt of this form.
CT-NUR
Verification of Licensure
This document must be completed by the licensing jurisdiction(s) of original licensure,
current state of licensure and any jurisdiction in which you have actively practiced
within the last 5 years. Verification of licensure for a previously held LPN license
within the last 5 years will only be required if you were not subsequently licensed in
the same jurisdiction as an RN.
Complete applicant section of form; then send form to each state or territory in which
you have ever held registered or practical nurse licensure. Completion of CT-NUR
form is not necessary if license is held in Illinois. Direct the licensing agency/board
to return the completed form to you and submit it with your application for licensure
and/or examination.
Copies of licenses are not
acceptable in lieu of an official
verification of licensure.
Important: The National Council of State Boards of Nursing (NCSBN) handles
verification of licensure for many state boards of nursing who licensure participate in
Nursys®. Please visit Nursys.com (www.nursys.com) or https://www.nursys.com/
NLV/LicenseVerificationJurisdictions.aspx to view a complete list.
If the state(s) where you have been licensed as a nurse licensure participates in Nursys®,
you must request verification of your licensure through Nursys® (www.nursys.com),
not the state(s). If your state(s) of licensure does not appear on the Nursys® list of
licensure participating boards of nursing, you must use the CT-NUR form (Verification
of Licensing Agency/Board) to verify your license to the Illinois Board of Nursing.
ED-NUR
Certification of Education
If you received your nursing education in the United States or one of its territories and
are applying for licensure under examination or endorsement, you must submit this
form. Complete the applicant section of this form, then send the form to the educational
institution at which you completed your registered nurse education program. The form
must be signed by the dean or director of your nursing education program with school
seal affixed. Direct the program to return the form to you and submit it with your application for licensure and/or examination.
TP-NUR
Temporary Permit
This form provides a means of applying for licensure pending the processing of an
endorsement/restoration application. The entire form is to be completed by the applicant. Failure to properly complete, sign and date this form will result in a delay in the
processing of your temporary endorsement or restoration permit.
VE
Verification of
Employment/Experience
Fill in the top portion of this form. Then submit it to your employer to be completed
by the Personnel Representative for Nursing Services. Instruct that person to fill out
the remainder of the form and return it to you for enclosure with the rest of your application. The purpose of this form is to provide proof of your active engagement in
nursing in another jurisdiction.
RS
Restoration
This is one of the forms you must complete to restore your Illinois Registered Nurse
license. The applicant is to complete the entire form and submit it with the other documentation as requested on page 7.
FP-NUR
Certifying Statement of
Fingerprint Submission
This form must be completed by all applicants for fingerprinting in the State of Illinois
unless a receipt issued by an approved fingerprint vendor is submitted.
Registered Nurse - Page 11
LICENSURE METHODS AND DEFINITIONS
Following are definitions of the various methods used in issuing licenses for professionals in the
State of Illinois. Some of these licensure methods may not be applicable to your profession. Refer
to the enclosed instruction sheet to determine the specific licensure methods/requirements for
your profession.
Licensure Methods
Definition
Examination
Applicant has applied or is required to take and pass all
or a portion of an exam scheduled and/or given by the
Department or a representative of the Department.
Endorsement of License
Original license issued in another state and that state's
requirements were substantially equivalent to Illinois
requirements at time license was issued.
Acceptance of Examination
Applicant has taken a National Exam, referred to by
Illinois statute, in any state. Applicant may or may not be
licensed in another state.
Restoration
Applicant has previously been licensed in State of Illinois
and has allowed license to lapse long enough to require
reapplication. Possible exam passage and/or committee
review.
Grandfather/Waiver
Applicant will be licensed without regard to current
requirements because statute allows this based on past
qualification and practices (for a specified time only).
Non-examination
Applicant is licensed by meeting qualifications required
by statute. There is no exam for these professions.
These can be either businesses or individuals.
DPR-I-DEFINE D 7/06
IMPORTANT NOTICE
Elder and Child Abuse Reporting
"Pursuant to Public Act 91-0244, effective January 1, 2000, if you have
reason to believe that an adult 60 years of age or older who resides
in a domestic living situation who, because of dysfunction is unable
to seek assistance for himself or herself has, within the previous 12
months been subject to abuse, neglect or financial exploitation, the
mandated reporter shall, within 24 hours after developing such belief,
report this suspicion to the Department on Aging. Reports should be
made to DEPARTMENT ON AGING AT 1-800-252-8966."
_____________________________________
"Public Act 91-0244 also requires that if you have reasonable cause
to believe a child known to you in your professional capacity may be
an abused or neglected child you are required to report such possible
neglect or abuse to the DEPARTMENT OF CHILDREN AND FAMILY
SERVICES AT 1-800-25abuse."
DPR-I-abuse 12/99
REFERENCE SHEET
ALL FEES ARE NONREFUNDABLE
Department reserves the right to change examination dates, filing deadlines and fees
if prevailing circumstances necessitate such action.
CHART I - PROFESSION NAME, PROFESSION CODE, LICENSURE METHOD & FEE
Profession Name
Profession
Code
Licensure
Method
Application
Fee
Registered Nurse
041
Examination (CTS)
Examination (NCSBN)
$98.00
$200.00
Registered Nurse
041
Endorsement of License
Temporary Permit
$50.00
$25.00
RegIstered Nurse
041
Restoration
Temporary Permit
See Supporting Document RS
$25.00
CHART II - EXAMINATION CODES AND FEES
Since the application for examination is a dual process, you must:
Complete the Department's licensure/examination application by applying online at www.continentaltesting.net
and pay the required administration fee as noted above; and
Register for the examination through the NCLEX Examination website at www.ncsbn.org/nclex.htm.
Once you have completed both processes and are determined eligible you will receive:
An Authorization to Test (ATT) that will contain the necessary information to schedule yourself for this examination.
The ATT eligibility lasts for 90 days only. You must take the examination within those 90 days or reapply with new
fees to CTS and Pearson Vue.
CHART III - EXAMINATION DATES - Information will be available once you are approved for the exam.
* * * * * REQUEST FOR ASSISTANCE * * * * *
If assistance is needed, direct your request (based upon your licensure method) to:
Licensure Methods Except Examination (US ONLY)
1-800-560-6420
Examination Licensure Method Only
TTY
1-866-325-4949
1-708-354-9911
Please allow 6 weeks from mailing your application
before making an inquiry concerning its status.
SEE REVERSE SIDE FOR CHART IV - SCHOOL CODES
DPR-RN 10/14
Reference Sheet - Page 1 of 2
CHART IV - SCHOOL CODES
ILLINOIS NURSING EDUCATION PROGRAMS - PROGRAMS PREPARING REGISTERED NURSES
AURORA
US49508100
Aurora University
BELLEVILLE
US49405500
Southwestern Illinois College
BLOOMINGTON
US49501100
Ill Wesleyan Univ
BOURBONNAIS
US49505000
Olivet Nazarene University
CANTON
US49305100
Graham Hospital
US49400200
Spoon River College
CARTERVILLE
US49404200
John A. Logan College
CENTRALIA
US49408600
Kaskaskia College
CHAMPAIGN
US49405200
Parkland College
CHICAGO
US49508200
Chicago State University
US49501000
DePaul University
US49408800
Kennedy-King College
US49508600
Loyola University
US49405300
Malcolm X College
US49509800
North Park University
US49405400
Olive-Harvey College
US49407700
Richard J. Daley College
US49400000
Robert Morris College
US49501600
Rush University
US49503000
Rush University Master's Entry
US49508400
St. Xavier University
US49401600
Truman College
US49501400
University of Illinois
US49502600
University of Illinois at Chicago--MSN
CHICAGO HTS.
US49406200
Prairie State College
CICERO
US49408700
Morton College
CRYSTAL LAKE
US49401000
McHenry County College
DANVILLE
US49500400
Lakeview College of Nursing
US49402300
Danville Area Community College
DE KALB
US49505900
Northern Illinois University
DECATUR
US49505800
Millikin University
US49403200
Richland Comm. College
DES PLAINES
US49405000
Oakton Community College
DIXON
US49405100
Sauk Valley College
EDWARDSVILLE
US49501300
Southern Illinois University
ELGIN
US49409200
Elgin Community College
ELMHURST
US49509100
Elmhurst College
FREEPORT
US49407000
Highland Community College
GALESBURG
US49408500
Carl Sandburg College
GLEN ELLYN
US49409500
College of DuPage
GODFREY
US49408300
Lewis & Clark Community College
DPR-RN 10/14
GRAYSLAKE
US49409000
College of Lake County
HARRISBURG
US49404400
Southeastern Illinois College
INA
US49404100
Rend Lake College
JACKSONVILLE
US49507800
MacMurray College
JOLIET
US49500300
University of St. Francis
College of Nursing and Allied Health
US49409900
Joliet Junior College
KANKAKEE
US49409600
Kankakee Community College
MACOMB
US49502300
Western Illinois University
MALTA
US49407600
Kishwaukee College
MATTOON
US49400100
Lake Land College
MOLINE
US49403300
Black Hawk College
US49404000
Trinity College of Nursing (ADN)
NORMAL
US49403400
Heartland Comm. College
US49505600
Mennonite College of Nursing
at Illinois State University
OAK PARK
US49505700
Concordia / Resurrection University
OGLESBY
US49405800
Illinois Valley Comm College
OLNEY
US49406600
Ill Eastern Comm Colleges
PALATINE
US49405600
Wm Rainey Harper College
PALOS HEIGHTS
US49508000
Trinity Christian College
PALOS HILLS
US49408400
Morraine Valley Comm College
PEORIA
US49500200
St. Francis Md. Ctr. Coll. Nsg.
US49504900
Bradley University
US49409700
Illinois Central College--East Peoria
US49506000
Methodist Medical Center College of
Nursing
QUINCY
US49504100
Blessing Riemer/Culver Stockton College
US49403100
John Wood Comm. College
RIVER GROVE
US49400600
Triton College
ROCKFORD
US49500500
Rockford College
US49500600
St. Anthony College of Nursing
US49405700
Rock Valley College
ROMEOVILLE
US49508300
Lewis University
SOUTH HOLLAND
US49406700
South Suburban College
SPRINGFIELD
US49500700
St. John's College
US49408000
Lincoln Land Community Coll.
SUGAR GROVE
US49408900
Waubonsee Comm College
ULLIN
US49404300
Shawnee Community College
Reference Sheet - Page 2 of 2
Illinois Department of Financial and Professional Regulation
Division of Professional Regulation
Application Checklist for Registered Nurses
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
Before you mail your application, check the following items to make sure your application is complete!
FOUR-PAGE APPLICATION REVIEW
Part I.
Application Category Information
Part II.
Applicant Identifying Information
Part III.
Education Information
Part IV.
Record of Licensure Information
Part V.
Record of Examination
Part VI.
Personal History Information
Part VII.
Examination Coding Information (if applicable)
Part VIII.
Child Support and/or Student Loan Information
Part IX.
Certifying Statement--Signed and Dated
SUPPORTING DOCUMENTS
COMPLETED
SUBMITTED
Application Fee - $50 application fee; $25 temporary permit fee; $75 total
Supporting Document CCA must be completed and submitted with each application.
Your application will not be processed without completion of this form.
ED-NUR Form with seal and signature affixed; or
Nursing transcripts with seal affixed.
CGFNS or CES Report
CT-NUR (Certification of Licensure) Form completed by state of original licensure and
any state in which you have practiced in the last five (5) years.
Verification requested from NURSYS (if applicable)
VE (Verification of Employment) Form (if applicable)
Proof of Name Change (if applicable)
Criminal Background Check Requested
Proof of Fingerprint Submission
TP-NUR Form (if applicable)
Copies of All Active Licenses (temporary permit only)
RS (Restoration) Form (if applicable). You must obtain this form by contacting the
Department at 1-800-560-6420.
Current NCLEX exam passage (if applicable)
All supporting documents may not be required. Please refer to application instructionsfor your specific method of licensure.
IL486-1971 (RN) 2/15
FOR OFFICIAL USE ONLY
APPLICATION FOR
LICENSURE AND/OR EXAMINATION
IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure
under 225 of the Illinois Compiled Statutes. Disclosure of this information is VOLUNTARY.
However, failure to comply may result in this form not being processed.
The following materials are required to make Application for
Licensure and/or Examination in Illinois:
Carefully follow all steps outlined on the INSTRUCTION SHEET. In
addition, note the following:
1.
A. Type or print legibly with black ink only.
Four page APPLICATION FOR LICENSURE AND/OR
EXAMINATION.
2. INSTRUCTION SHEET, which gives step by step application instructions for your profession.
3. REFERENCE SHEET, which gives detailed coding
information for your profession.
4. SUPPORTING DOCUMENTS, forms, and/or any other
documentation you may be required to submit with
your application.
5. If the name shown on your supporting documents is different from that shown on your application, you must submit
PROOF OF LEGAL NAME change - copy of marriage
license, divorce decree, affidavit or court order.
PART I: Application Category Information
B. FEES ARE NOT REFUNDABLE.
C. Disclosure of your U.S. social security number, if you have one, is
mandatory, in accordance with 5 Illinois Compiled Statutes 100/10-65
to obtain a license. The social security number may be provided to
the Illinois Department of Public Aid to identify persons who are more
than 30 days delinquent in complying with a child support order, or
to the Illinois Department of Revenue to identify persons who have
failed to file a tax return, pay tax, penalty or interest shown in a filed
return, or to pay any final assessment or tax penalty or interest, as
required by any tax Act administered by the Illinois Department of
Revenue, or to other entities for verification of identification.
A. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4
3. LICENSURE METHOD
1. PROFESSION NAME
2. PROFESSION CODE
4. FEE
$
B. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION
This is the first time I have made application for this
profession in Illinois.
My application for this profession had previously been denied
in Illinois. I am reapplying since I have fulfilled additional
requirements.
I have previously made application for this profession in
Illinois. However, my previous application expired and I
am now reapplying.
I have previously made application for this profession in
Illinois. However, I am now applying under new statutory
language.
Other:
PART II:
1. NAME
Applicant Identifying Information--You must notify the Department of Financial and Professional Regulation Division of Professional Regulation and/or Continental Testing Service in writing, of any address changes after you
file this application in order to receive any further information.
LAST
FIRST
4. PERMANENT MAILING ADDRESS
5. BUSINESS ADDRESS
MIDDLE
STREET
STREET
2. TITLE (e.g., M.D., D.D.S., etc.)
CITY
STATE/COUNTRY
ZIP CODE
COUNTY
CITY
STATE/COUNTRY
ZIP CODE
COUNTY
6. MAIDEN, GIVEN SURNAME, OR ANY NAME(S) UNDER WHICH SUPPORTING
DOCUMENTS WILL BE SUBMITTED. (SEE INSTRUCTIONS #5 ABOVE)
8. PLACE OF BIRTH
CITY
3. UNITED STATES SOCIAL SECURITY NO.
STATE/COUNTRY
7. MOTHER'S MAIDEN NAME
10. AGE
9. DATE OF BIRTH
Month
Day
Year
11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED
__
Work: ( __ __ __ ) __ __ __ __ __ __ __
__
Home: ( __ __ __ ) __ __ __ __ __ __ __
(Area Code)
Fax:
( __ __ __ ) __ __ __ __ __ __ __
IL486-1019 01/14 (LT)
12. PREFERRED e-MAIL
ADDRESS(ES) [If available]
(Area Code)
__
(Area Code)
Female
Male
Fax:
( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code)
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4
Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.com.
1. PRELIMINARY EDUCATION (Elementary and High School or G.E.D. Circle number of years completed)
1 2 3 4 5 6 7 8 9 10 11 12
2. NAME OF LAST PRELIMINARY SCHOOL
ATTENDED
Graduated
High School?
Yes
Received
OR G.E.D.?
No
3. LAST PRELIMINARY SCHOOL LOCATION
(City and State)
Yes
No
4. DATE OF GRADUATION
Month
Year
5. COLLEGE OR UNIVERSITY (Circle number of years completed)
1 2 3 4 5 6 7 8
6. COLLEGE OR UNIVERSITY NAME
(Undergraduate and Graduate)
Graduated?
Yes
LOCATION
(City and State or Country)
No
DATES OF ATTENDANCE
FROM
TO
Month/Year
Month/Year
7. SPECIALIZED TRAINING (Residency, Professional Training, Vocational Training, Practical or Clinical Training)
DATES OF ATTENDANCE
LOCATION
INSTITUTION NAME
(City and State or Country)
TO
FROM
Month/Year
IL486-1019
TYPE OF
DEGREE EARNED
Did You Complete
Training?
Month/Year
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 2 of 4
NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________
PART III: Education Information
If you have ever been licensed to practice the profession for which you are now making application, or held a related license, complete
the information requested below. If you have ever held a temporary, trainee or apprenticeship license, or a permit, it must be listed here
also. In addition, the INSTRUCTION SHEET enclosed with this Application package may instruct you to have Certification(s) of Licensure in other state(s) prepared and submitted in support of your application (contact other state(s) regarding possible fee). You must
also list all other licenses held in Illinois, however, certification of licensure from Illinois is not required. Failure to disclose all licenses
held may result in denial of your application or other appropriate action.
STATE
PROFESSION NAME
LICENSE NUMBER
DATE OF
ISSUANCE
LICENSE STATUS
(Active, Lapsed, etc.)
State of Original Licensure
State of Current Licensure where you
most recently have been practicing.
Other States of Licensure
(If additional space is needed, attach a separate sheet.)
PART V: Record of Examination
If you have ever taken a licensure examination in Illinois or any other state for the profession for which you are now making
application, you must complete the information requested below. EACH EXAMINATION ATTEMPT MUST BE SHOWN.
Failure to disclose an examination attempt may result in the denial of your application or other appropriate action.
NAME OF EXAMINATION
STATE
MONTH/YEAR
EXAM RESULTS
(Passed, Failed, Absent)
(If additional space is needed, attach a separate sheet.)
IL486-1019
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 3 of 4
NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________
PART IV: Record of Licensure Information
YES NO
1. Have you been convicted of or pled guilty or nolo contendere to any criminal offense in any state or in federal court? Please do not give
details on minor traffic charges, but do include information relating to Driving While Intoxicated (DWI) charges. If yes, attach a certified
copy of the court records regarding your conviction, the nature of the offense and date of discharge, if applicable, as well as a statement
from the probation or parole office.
2. Have you been convicted of a felony?
3. If yes, have you been issued a Certificate of Relief from Disabilities by the Prisoner Review Board? If yes, attach a copy of the certificate.
4. Have you had or do you now have any disease or condition that interferes with your ability to perform the essential functions of your profession, including any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease
or condition; (2) alcohol or other substance abuse; (3) physical disease or condition, that presently interferes with your ability to practice
your profession? If yes, attach a detailed statement, including an explanation whether or not you are currently under treatment.
5. Have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license or permit
disciplined in any way by any licensing authority in Illinois or elsewhere? If yes, attach a detailed explanation.
6. Have you ever been discharged other than honorably from the armed service or from a city, county, state or federal position? If yes, attach
a detailed explanation.
PART VII: Examination Coding Information (This part is for examination applicants only)
Refer to the REFERENCE SHEET enclosed with this application package and complete the following:
a) CHART II -
Select examination(s) you desire
and enter Test Codes.
b) CHART III -
Select the examination site you desire and enter Test Center Code:
c) CHART IV -
Find your School of Graduation and enter school code:
d) Record the number of times you have taken this exam in Illinois or any other state:
PART VIII: Child Support and/or Student Loan Information (Every applicant is required by law to respond to the
following questions)
1.
In accordance with 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's
Social Security number, and the licensee shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying
with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to
contempt of court.
Are you more than 30 days delinquent in complying with a child support order?
(NOTE: If you are not subject to a child support order, answer "no.")
2.
Yes
No
In accordance with 20 Illinois Compiled Statutes 2105/2105-(5), "The Department shall deny any license or renewal authorized by the Civil
Administrative Code of Illinois to any person who has defaulted on an educational loan or scholarship provided by or guaranteed by the Illinois
Student Assistance Commission or any governmental agency of this State; however, the Department may issue a license or renewal if the
aforementioned persons have established a satisfactory repayment record as determined by the Illinois Student Assistance Commission or other
appropriate governmental agency of this State." (Proof of a satisfactory repayment record must be submitted.)
Are you in default on an educational loan or scholarship provided/guaranteed by the Illinois
Student Assistance Commission or other governmental agency of this State?
PART IX:
Yes
No
Certifying Statement
Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me
in connection therewith, and to the best of my knowledge, they are true, correct, and complete.
Signature of Applicant
Date
I UNDERSTAND THAT FEES ARE NOT REFUNDABLE. My signature above authorizes the Department of Financial and Professional
Regulation to reduce the amount of this check if the amount submitted is not correct. I understand this will be done only if the amount
submitted is greater than the required fee hereunder, but in no event shall such reduction be made in an amount greater than $50.
IL486-1019
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 4 of 4
NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________
PART VI: Personal History Information (This part must be completed by all applicants)
IMPORTANT NOTICE: Completion of
this form is necessary to accomplish the
requirements outlined in 225 of the Illinois
Compiled Statutes. Disclosure of this
information is VOLUNTARY. However,
failure to comply may result in this form not
being processed.
1. NAME
LAST
SUPPORTING DOCUMENT
HEALTH CARE WORKERS
CHARGED WITH OR CONVICTED
OF CRIMINAL ACTS
FIRST
MIDDLE
CCA
3. PROFESSIONAL LICENSE NUMBER (if any)
__ __ __ - __ __ __ __ __ __
2. ADDRESS
STREET,
CITY,
STATE,
ZIP CODE
4. SOCIAL SECURITY NUMBER
__ __ __ - __ __ - __ __ __ __
Pursuant to 20ILCS 2105-165(a), the Department requires the following professionals to disclose information regarding
convictions pertaining to certain offenses. Please check applicable profession.
Acupuncturists
Advanced Practice Nurses
Athletic Trainers
Audiologists
Clinical Psychologists
Clinical Social Workers
Dental Hygienists
Dentists
Genetic Counselors
Licensed Clinical Professional
Counselors
Licensed Practical Nurses
Licensed Social Workers
Marriage and Family Therapists
Physician Assistants
Podiatrists
Professional Counselors
Prosthetists
Registered Nurses
Registered Surgical Assistants
Registered Surgical Technologists
Respiratory Care Practitioners
Speech Pathologists
Naprapaths
Nursing Home Administrators
Occupational Therapists
Occupational Therapy Assistants
Optometrists
Orthotists
Pedorthists
Perfusionists
Pharmacists
Physical Therapists
Physical Therapy Assistants
Physicians, including Medical Doctors (M.D.), Doctors
of Osteopathic Medicine (D.O.), and Chiropractic
Physicians (D.C.)
Any other license issued by the Department under the Acts listed in this Section and the Controlled Substances Act [740
ILCS 40], except for pharmacy technicians, issued to a person subject to the Code and this Part.
In order for your application to be evaluated, you must respond to each of the following questions:
Yes
1)
Are you currently charged with or have you been convicted of a criminal act that requires registration
under the Sex Offender Registration Act? *
2)
Are you currently charged with or have you been convicted of a criminal battery against any patient in the
course of patient care or treatment, including any offense based on sexual conduct or sexual penetration?
3)
Are you required, as part of a criminal sentence, to register under the Sex Offender Registration Act? *
4)
Are you currently charged with or have you been convicted of a forcible felony? *
No
If YES to any of the above, attach a certified copy of the court records regarding your conviction, the nature of the offense
and date of discharge, if applicable, as well as a statement from the probation or parole office.
Certification Statement
Under penalties of perjury, I declare that I have examined this Form and all supporting documents and/or information
submitted by me in connection therewith, and to the best of my knowledge, they are true, correct, and complete.
Signature of Applicant
IL486-2034 02/13 (crimacts)
Date
Page 1of 3
* DEFINITIONS
730 ILCS 150 et. seq:—Acts that require Sex Offender Registration:
(B) As used in this Article, “sex offense” means:
(1) A violation of any of the following Sections of the Criminal Code of 1961:
11-20.1 (child pornography),
11-20.3 (aggravated child pornography),
11-6 (indecent solicitation of a child),
11-9.1 (sexual exploitation of a child),
11-9.2 (custodial sexual misconduct),
11-9.5 (sexual misconduct with a person with a disability),
11-15.1 (soliciting for a juvenile prostitute),
11-18.1 (patronizing a juvenile prostitute),
11-17.1 (keeping a place of juvenile prostitution),
11-19.1 (juvenile pimping),
11-19.2 (exploitation of a child),
11-25 (grooming),
11-26 (traveling to meet a minor),
12-13 (criminal sexual assault),
12-14 (aggravated criminal sexual assault),
12-14.1 (predatory criminal sexual assault of a child),
12-15 (criminal sexual abuse),
12-16 (aggravated criminal sexual abuse),
12-33 (ritualized abuse of a child).
An attempt to commit any of these offenses.
(1.5) A violation of any of the following Sections of the Criminal Code of 1961, when the victim is a person under 18 years of age, the
defendant is not a parent of the victim, the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act, and the offense was committed on or after January 1, 1996:
10-1 (kidnapping),
10-2 (aggravated kidnapping),
10-3 (unlawful restraint),
10-3.1 (aggravated unlawful restraint).
(1.6) First degree murder under Section 9-1 of the Criminal Code of 1961, when the victim was a person under 18 years of age and
the defendant was at least 17 years of age at the time of the commission of the offense, provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.
(1.7) (Blank).
(1.8) A violation or attempted violation of Section 11-11 (sexual relations within families) of the Criminal Code of 1961, and the offense
was committed on or after June 1, 1997.
(1.9) Child abduction under paragraph (10) of subsection (b) of Section 105 of the Criminal Code of 1961 committed by luring or attempting to lure a child under the age of 16 into a motor vehicle, building, house trailer, or dwelling place without the consent of the
parent or lawful custodian of the child for other than a lawful purpose and the offense was committed on or after January 1, 1998,
provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.
(1.10) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed
on or after July 1, 1999:
10-4 (forcible detention, if the victim is under 18 years of age), provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act,
11-6.5 (indecent solicitation of an adult),
11-15 (soliciting for a prostitute, if the victim is under 18 years of age),
11-16 (pandering, if the victim is under 18 years of age),
11-18 (patronizing a prostitute, if the victim is under 18 years of age),
11-19 (pimping, if the victim is under 18 years of age).
(1.11) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed
on or after August 22, 2002:
11-9 (public indecency for a third or subsequent conviction).
(1.12) A violation or attempted violation of Section 5.1 of the Wrongs to Children Act (permitting sexual abuse) when the offense was
committed on or after August 22, 2002.
(2) A violation of any former law of this State substantially equivalent to any offense listed in subsection (B) of this Section.
(C) A conviction for an offense of federal law, Uniform Code of Military Justice, or the law of another state or a foreign country that is
substantially equivalent to any offense listed in subsections (B), (C), (E), and (E5) of this Section shall constitute a conviction for
the purpose of this Article.
IL486-2034 02/13 (crimacts)
Page 2 of 3
* DEFINITIONS
A “forcible felony”, for the purposes of Section 2105-165 of the Code (section numbers are from
the Criminal Code of 1961 [720 ILCS 5]) and 68 Illinois Administrative Code 1130.120 is one or
more of the following offenses:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
n)
o)
p)
q)
r)
s)
t)
u)
v)
w)
x)
y)
z)
aa)
bb)
cc)
dd)
ee)
ff)
gg)
hh)
ii)
jj)
kk)
First Degree Murder (Section 9-1);
Intentional Homicide of an Unborn Child (Section 9-1.2);
Second Degree Murder (Section 9-2);
Voluntary Manslaughter of an Unborn Child (Section 9-2.1);
Drug-induced Homicide (Section 9-3.3);
Kidnapping (Section 10-1);
Aggravated Kidnapping (Section 10-2);
Unlawful Restraint (Section 10-3);
Aggravated Unlawful Restraint (Section 10-3.1);
Forcible Detention (Section 10-4);
Involuntary Servitude (Section 10-9(b));
Involuntary Sexual Servitude of a Minor (Section 10-9(c));
Trafficking in Persons (Section 10-9(d));
Criminal Sexual Assault (Section 11-1.20);
Aggravated Criminal Sexual Assault (Section 11-1.30);
Predatory Criminal Sexual Assault of a Child (Section 11-1.40);
Criminal Sexual Abuse (Section 11-1.50);
Aggravated Criminal Sexual Abuse (Section 11-1.60);
Aggravated Battery (Section 12-3.05);
Compelling Organization Membership of Persons (Section 12-6.5);
Compelling Confession or Information by Force or Threat (Section 12-7);
Home Invasion (Section 12-11);
Robbery (Section 18-1);
Armed Robbery (Section 18-2);
Vehicular Hijacking (Section 18-3);
Aggravated Vehicular Hijacking (Section 18-4);
Aggravated Robbery (Section 18-5);
Terrorism (Section 29D-14.9);
Causing a Catastrophe (Section 29D-15.1);
Possession of a Deadly Substance (Section 29D-15.2);
Making a Terrorist Threat (Section 29D-20);
Falsely Making a Terrorist Threat (Section 29D-25);
Material Support for Terrorism (Section 29D-29.9);
Hindering Prosecution of Terrorism (Section 29D-35);
Boarding or Attempting to Board an Aircraft with Weapon (Section 29D-35.1);
Armed Violence (Section 33A-2); and
Attempt (Section 8-4) of any of the above specified offenses.
IL486-2034 02/13 (crimacts)
Page 3 of 3
IMPORTANT NOTICE: Completion of this
form is necessary for consideration for
licensure under 225 ILCS 65/1 et.seq. of
(Illinois Compiled Statutes). Disclosure of this
information is VOLUNTARY. However, failure
to comply may result in this form not being
processed.
SUPPORTING DOCUMENT
VERIFICATION BY LICENSING
AGENCY/BOARD
CT-NUR
APPLICANT: Complete the applicant section of this form then forward this form to the state or territory in which
you are requesting verification of your examination status, license or examination scores. Contact
certifying jurisdiction for appropriate fee. Photocopying this form is permissible.
1.
NAME
LAST
FIRST
MIDDLE
2.
DATE OF BIRTH
3.
SOCIAL SECURITY NUMBER
__ __ / __ __ / __ __ __ __
Month
4.
ADDRESS STREET, CITY, STATE, ZIP CODE
6.
MAIDEN OR GIVEN SURNAME
5.
Day
Year
REFER TO REFERENCE SHEET. Record profession name and three
digit profession code for which you are making Illinois application.
Profession Code
Profession Name
7.
APPLICANT TELEPHONE NUMBER (Daytime)
Area Code (
7a. RECORD PROFESSION NAME AS IT APPEARS ON YOUR LICENSE
FROM THE JURISDICTION TO WHICH THIS FORM IS BEING FORWARDED.
(If applicable)
)
7b. LICENSE NUMBER
(If applicable)
I hereby authorize
7c. ISSUANCE DATE OF LICENSE
(If applicable)
to furnish to the Illinois Department of
Name of Licensing Agency or Board
Financial and Professional Regulation or its designated testing service, the information requested below.
Signature
Date
LICENSING AGENCY:
RETURN COMPLETED FORM TO APPLICANT
Complete the remainder of this form. Use Part V on the reverse side of this form for any
additional information relating to the examination status of the above-named applicant
which has not been provided on this form (i.e. wrote the National State Board Test Pool
Examination, etc.) Please record N/A in areas which are not applicable.
PART I. - VERIFICATION OF EXAMINATION STATUS
A. The applicant
has written the following examination
times.
is scheduled for the following examination on __ __ / __ __ / __ __ __ __
Month
NAME OF EXAMINATION
DATE OF
EXAMINATION
RESULTS
Passed
Failed
Day
Year
DATE OF
EXAMINATION
RESULTS
Passed
Failed
National Council Licensure Examination
for Registered Nurses (NCLEX-RN)
National Council Licensure Examination
for Practical Nurses (NCLEX-PN)
B. Nursing Education Program Completed.
Name of Program
Location of Program
C. Does your state require the Council of Graduates of Foreign Nursing Schools Examination for
those Registered Nurses who received their nursing education outside the United States?
IL486-0307 04/06 (NS)
Year of Graduation
Yes
No
CT-NUR - Verification by Licensing Agency/Board - Page 1 of 2
B. LICENSE NUMBER
C. ISSUANCE DATE OF LICENSE
D. EXPIRATION DATE OF LICENSE
E. LICENSURE METHOD
Examination - Date
National Council
Licensure Examination
State Constructed
Other (Name)
F.
Endorsement of License (State)
Acceptance of Examination Results
Administered in Another State
Waiver/Grandfather
Other (Describe)
CURRENT LICENSURE STATUS
Active
Inactive
Lapsed
Other (explain)
PART III. - VERIFICATION OF EXAMINATION SCORES
A. National
N.S.B.T.P.E.
RESULTS
LPN
REGISTERED NURSE
MEDICAL
NURSING
PSYCHIATRIC
NURSING
OBSTETRIC
NURSING
SURGICAL
NURSING
NURSING OF
CHILDREN
NCLEX/COMP.
EXAM
NCLEX/COMP.
EXAM
Standard Scores
Series/Form No.
B. State Constructed Examination
Registered Nurse
SUBJECT
SCORE
Licensed Practical Nurse
SUBJECT
SCORE
PART IV. - FORMAL ACTIONS
A. Is there now or has there ever been any formal action commenced against the applicant?
Yes
No
B. Have there ever been any formal sanctions imposed against the applicant as a matter of public
record including but not limited to fine, reprimand, probation, censure, revocation, suspension,
surrender, restriction or limitation? (If yes, attach a certified copy of disciplinary action.)
Yes
No
PART V. - ADDITIONAL INFORMATION
I certify that the information contained herein is true and correct according to the official records of the State.
Print Name
SEAL
Title
Signature
Agency/Board Street Address
Date
Area Code (
City, State, ZIP Code
)
Telephone Number
Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT.
Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.
IL486-0307 04/06 (NS)
CT-NUR - Verification by Licensing Agency/Board - Page 2 of 2
NAME (Last, First, MI): _____________________________________________ SS#: _____________________ Profession: ___________________
PART II. - VERIFICATION OF LICENSURE
A. NAME OF PROFESSION AS IT APPEARS ON LICENSE
IMPORTANT NOTICE: Completion of this
form is necessary for consideration for
licensure under 225 ILCS 65/1 et.seq. of
(Illinois Compiled Statutes). Disclosure of
this information is VOLUNTARY. However,
failure to comply may result in this form not
being processed.
APPLICANT:
1. NAME
SUPPORTING DOCUMENT
ED-NUR
CERTIFICATION OF EDUCATION
Complete the applicant section of this form, then forward it to the school for completion of the
remainder of the form.
LAST
FIRST
MIDDLE
2. DATE OF BIRTH
3. SOCIAL SECURITY NUMBER
__ __ / __ __ / __ __ __ __
4. ADDRESS
STREET
CITY
STATE
ZIP CODE
Month
Day
Year
5. REFER TO REFERENCE SHEET. Record profession name and three
digit profession code for which you are making Illinois application.
6. MAIDEN OR GIVEN SURNAME
Profession Name
7. NAME OF INSTITUTION ATTENDED
Profession Code
8. DATE OF GRADUATION/COMPLETION
__ __ / __ __ / __ __ __ __
Month
Day
Year
I hereby authorize a school official of the institution named above to furnish to the Illinois Department of Financial and
Professional Regulation or its designated testing service the information requested below.
Date
SCHOOL OFFICIAL:
Signature of Applicant
Complete the bottom portion of this page and the reverse side, then return to the
applicant.
A. NAME OF INSTITUTION
B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE
C. DEPARTMENT OF INSTITUTION
D. MAJOR AREA OF STUDY OF THE APPLICANT
E. DATES OF ATTENDANCE
From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __
F.
Total academic years attended
OR
Total calendar years attended
Years
Months
Days
Years Months
Days
H. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS
WERE MET
__ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
G. TYPE OF DEGREE OR CERTIFICATE AWARDED (e.g., BA., MA.,
Ph.D.)
I. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED
__ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
J. IF EDUCATION PROGRAM WAS COMPLETED IN LESS THAN THE NORMALLY REQUIRED TIME, PLEASE EXPLAIN:
IL486-1031 05/14 (NS)
ED-NUR - Certification of Education - Page 1 of 2
NCSBN Number
SUBMISSION OF THIS FORM PRIOR TO PROGRAM COMPLETION WILL RESULT IN ITS RETURN TO THE
PROGRAM FOR CORRECTION.
I certify that the educational information recorded herein is true and correct according to the official records of this
institution.
Print Name of Dean or Director of Nursing
License Number
Signature of Dean or Director of Nursing
Date
Title
SCHOOL SEAL OR NOTARY SEAL
NOTE: If the institution does not have a school seal, this form must be notarized.
Subscribed and sworn before me this ______day of_________________, 20____.
Date of Expiration
Signature of Notary Public
RETURN THIS FORM TO APPLICANT
IL486-1031 05/14 (NS)
ED-NUR - Certification of Education - Page 2 of 2
NAME (Last, First, MI): ______________________________________________ SS#: _____________________ Profession: ___________________
K. NURSING SCHOOL PROGRAM CODE
SUPPORTING DOCUMENT
IMPORTANT NOTICE: Completion of
this form is necessary to accomplish the
requirements outlined in 225 of the Illinois
Compiled Statutes. Disclosure of this
information is VOLUNTARY. However,
failure to comply may result in this form not
being processed.
VERIFICATION OF
EMPLOYMENT / EXPERIENCE
VE
APPLICANT: Complete the application section of this form, then forward it to your employer. Upon receipt of the
completed form from the employer, include it with your Application for Licensure/Examination. You
are authorized to photocopy this form as necessary.
1. NAME
LAST
FIRST
MIDDLE
3. SOCIAL SECURITY NUMBER
2. DATE OF BIRTH
__ __ __ - __ __ - __ __ __ __
__ __ / __ __ / __ __ __ __
Month
4. ADDRESS
STREET,
CITY,
STATE,
ZIP CODE
Day
Year
5. REFER TO REFERENCE SHEET. Record profession name and
three digit profession code for which you are making Illinois application.
___ ___ ___
Profession Code
Profession Name
6. MAIDEN OR GIVEN SURNAME
7. JOB TITLE OR POSITION APPLICANT HELD
8. DATES OF EMPLOYMENT
9. SUPERVISOR NAME
From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __
Month
Day
EMPLOYER:
Year
Month
Day
Year
Complete the remainder of this form. Return the completed form to the applicant in a sealed
envelope.
PART I - EMPLOYMENT INFORMATION
A. EMPLOYER NAME
B. BUSINESS / INSTITUTION NAME
C. EMPLOYER REGISTRATION/LICENSE NUMBER
D. STATE OF EMPLOYER
REGISTRATION/LICENSE
E. BUSINESS ADDRESS
F. BUSINESS REGISTRATION/LICENSE NUMBER (If Applicable)
G. STATE OF BUSINESS
REGISTRATION/LICENSE
H. BUSINESS TELEPHONE NUMBER
STREET
CITY
STATE
ZIP CODE
Area Code (___ ___ ___) ___ ___ ___ _ ___ ___ ___ ___
PART II - APPLICANT EMPLOYMENT INFORMATION
A. NUMBER OF HOURS WORKED
PER WEEK
B. TYPE OF EMPLOYMENT
[ ]Full-time
[ ]Part-time
C. DATES OF EMPLOYMENT
From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __
Month
Day
Year
Month
D. RECORD APPLICANT'S POSITION TITLE(S)
E. GIVE BRIEF DESCRIPTION OF DUTIES PERFORMED BY THE APPLICANT.
I do hereby declare that this information is true and correct.
Signature
Date
IL486-1348 04/06 (L&T)
Title
Day
Year
IMPORTANT NOTICE: Completion of this form is
necessary for consideration for licensure under 225
ILCS 65/1 et.seq. of (Illinois Compiled Statutes).
Disclosure of this information is VOLUNTARY.
However, failure to comply may result in this form
not being processed.
SUPPORTING DOCUMENT
TEMPORARY PERMIT
TP-NUR
APPLICANT: This form must be completed in its entirety and accompanied by the four (4) page application jacket.
1.
NAME
LAST
FIRST
MIDDLE
2.
DATE OF BIRTH
3.
SOCIAL SECURITY NUMBER
__ __ / __ __ / __ __ __ __
4.
ADDRESS STREET, CITY, STATE, ZIP CODE
6.
MAIDEN OR GIVEN SURNAME
5.
Month
Day
Year
REFER TO REFERENCE SHEET. Record profession name and three
digit profession code for which you are making Illinois application.
Profession Code
Profession Name
7. Nursing Education Program Completed.
Location of Program
Name of Program
Year of Graduation
8. Licensure examination taken in your state of original licensure which was the basis for your initial licensure:
NAME OF EXAMINATION
DATE OF
EXAMINATION
RESULTS
Passed
Failed
DATE OF
EXAMINATION
RESULTS
Passed
Failed
National Council Licensure Examination
for Registered Nurses (NCLEX-RN)
National Council Licensure Examination
for Practical Nurses (NCLEX-PN)
Other:
9. List all states where you hold active current licenses for the profession for which you are now making application:
10. Which one of the states noted above is the state where you have most recently been practicing?
11. Have you been convicted of any crime under the laws of any jurisdiction of the United States: (a) which is a felony; or
(b) which is a misdemeanor directly related to the practice of the profession within the last five (5) years?
Yes No
If so, submit certified copies of all court records pertaining to said conviction.
12. Have you had a license or permit related to the practice of nursing revoked, suspended, or placed on probation by another
jurisdiction within the last five (5) years?
Yes
No
If so, have appropriate board of nursing complete CT-NUR form and attach copies of disciplinary action.
I certify the information and documents contained in this application are true and correct to the best of my knowledge. I
understand should any of the information or documents contained herein be proven false, it may result in the denial of my
Temporary Permit request and/or permanent endorsement/restoration application or other appropriate disciplinary action.
Signature
IL486-1577 12/00 (NS)
Date
IMPORTANT NOTICE
CRIMINAL BACKGROUND CHECK INFORMATION
Individuals applying for licensure for professions that require fingerprints must submit to a criminal background check and provide evidence of fingerprint processing from a fingerprint vendor licensed by the
Department. Fingerprints must be taken within 60 days from the date that the application is submitted to
the Department or the Department’s testing vendor.
Applicants may contact a licensed fingerprint vendor to schedule an appointment for fingerprinting
by going to https://www.idfpr.com/FPVendor.asp. The Illinois State Police will transmit electronic
results of fingerprint processing to the Department. A receipt issued by a licensed fingerprint vendor agency must be submitted with the application fee. The receipt shall be issued by the fingerprint
vendor at the time the fingerprints are obtained.
Out-of-State applicants who are unable to schedule an appointment for fingerprinting through a
licensed fingerprint vendor need to complete the following steps:
Obtain one (1) Illinois State Police (ISP) Fee Applicant Card for processing. Applicants may
contact the Department at 1-800-560-6420 or send an email request on your profession
page of the Department website at www.idfpr.com. The ISP will transmit electronic results
of the fingerprint processing to the Department.
Complete Section 1 of the Identity Verification Certifying Statement form.
The Fee Applicant Card shall be taken to a police department in another state to obtain
classifiable prints.
Section 2 of the Identity Verification Certifying Statement shall be completed and signed
by the police department.
Go to www.idfpr.com to select a licensed fingerprint vendor that has “Card Scan” capability.
Contact the vendor to determine the fee for a “Card Scan”.
Mail the original Identity Verification Certifying Statement (with Sections 1 and 2 completed),
Fee Applicant card and fingerprint fee to the licensed fingerprint vendor selected from the
Division of Professional Regulation website.
Mail the completed application, licensing fee and a copy of the Identity Verification Certifying
Statement (with Sections 1 and 2 completed) to the Division of Professional Regulation.
PRIVACY STATEMENT
I, the undersigned, hereby authorize the release of any criminal history record information that may exist
regarding me from any agency, organization, institution, or entity having such information on file. I am aware
and understand that my fingerprints may be retained and will be used to check the criminal history record
information files of the Illinois State Police and/or the Federal Bureau of Investigation. I also understand that if
my photo was taken, my photo may be shared only for employment or licensing purposes. I further understand
that I have the right to challenge any information disseminated from these criminal justice agencies regarding
me that may be inaccurate or incomplete pursuant to Title 28 Code of Federal Regulation 16.34 and Chapter 20
ILCS 2630/7 of the Criminal Identification Act.
IL486-2052 NEW
4/15
IMPORTANT NOTICE: Completion of
this form is necessary for licensure/
employment under provision set forth
within the Illinois Compiled Statutes or
other related Federal laws. Disclosure
of this information is VOLUNTARY.
However, failure to comply may result
in the denial of your application.
IDENTITY VERIFICATION CERTIFYING
STATEMENT
OOS-FP
Pursuant to Title 68 Part 1240.535 of the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and
Locksmith Act of 2004 Rules, fingerprint vendors are required to confirm identity of the individual seeking to be fingerprinted. This identity verification form must be completed for out-of-state residents applying for licensure/employment in
the State of Illinois. This form will be utilized to confirm the personal identifying information being placed on the Illinois
State Police (ISP) Fee Applicant fingerprint card, form number ISP-404. The out-of-state agency chosen to take your
fingerprints, must complete this form, as written confirmation that a valid government issued drivers license or State ID
was presented and that the identification provided, belongs to the individual being fingerprinted.
Instructions: This form must be submitted, along with a manual Fee Applicant fingerprint card to which your fingerprints have been applied, to a licensed live scan fingerprint vendor in the State of Illinois possessing “Scan Card” capability to ensure electronic transmission of the Fee Applicant fingerprint card. The electronic transmission of fingerprints
to the ISP is mandated pursuant to Title 20 Part 1265 “Electronic Transmission of Fingerprints”. The manual submission of fingerprints to ISP is no longer acceptable. Once your fingerprints have been taken, a signed original of this
form must be attached to your Fee Applicant fingerprint card and submitted to an Illinois licensed live scan fingerprint
vendor. As well, an additional copy may be required to be submitted to the requesting State Agency along with any additional application or required documentation specified by the State Agency.
Section 1 Applicant Information (All fields mandatory)
LAST NAME:
FIRST:
PHONE NUMBER:
MIDDLE:
POSITION / REASON FINGERPRINTED: (NURSE/DOCTOR/SECURITY GUARD, ETC)
MAIDEN NAME/GIVEN SURNAME:
ADDRESS: (STREET/CITY/STATE/ZIP)
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
Section 2 Certifying Agency Taking Fingerprints (Include TCN from Fee Applicant card)
AGENCY NAME:
TCN: FRM
DATE FINGERPRINT TAKEN:
PRINTING AGENT’S NAME:
/
/
LAST
CONTACT PHONE NUMBER:
(
)
-
FIRST
I have compared the government issued identification presented by the applicant and attest that to the
best determination, I have fingerprinted the same individual. (Must be checked to certify)
PRINTING AGENT’S SIGNATURE:
Illinois Live Scan Fingerprint Vendor Information
Section 3 Fingerprint Vendor Agency Name
LIVE SCAN FP AGENCY NAME:
REQUESTING STATE AGENCY:
REQUESTING STATE AGENCY ORI:
DATE FINGERPRINTS SUBMITTED TO ISP:
COST CENTER USED:
IL486-2222
4/15
REGISTERED NURSE
Examination
Endorsement
Restoration
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
In accordance with the Illinois Nurse Practice Act, "For the protection of life and the promotion of health, and the prevention of illness and communicable diseases, any person practicing or offering to practice professional and practical
nursing in Illinois shall submit evidence that he or she is qualified to practice, and shall be licensed as hereinafter provided." A copy of the Illinois Nurse Practice Act and the Rules can be downloaded from the IDFPR Web Site at www.
idfpr.com. If you are issued a registered nurse license, please be advised that your license will expire on May 31st of
every even-numbered year.
Table of Contents
Page
Applying for Licensure ..............................................................................2
General Instructions ..............................................................................2
Examination
...........................................................................................2
General Examination Instructions .........................................................2
Practice Pending Licensure ...................................................................3
Practice Under Supervision ...................................................................3
Educated Inside U.S. or one of its Territories .......................................3
Educated Outside U.S. or one of its Territories .....................................4
Endorsement
...........................................................................................5
General Endorsement Instructions ........................................................5
Temporary Permit ..................................................................................6
Educated Inside U.S. or one of its Territories .......................................6
Educated Outside U.S. or one of its Territories .....................................7
Restoration
...........................................................................................8
General Restoration Instructions ...........................................................8
Temporary Permit ..................................................................................9
Forms Completion Guide ................................................................. 10-11
Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.com.
DPR-RN Instructions Revised 3/15
Packet updated 5/15/15
APPLYING FOR LICENSURE
General Instructions
1. Apply Directly On-Line. Register for the examination by referring to the
Continental Testing Web site (www.continentaltesting.net) for information
on how to apply for the examination on-line and pay the test fee by credit
card. If you are licensed in another U.S. jurisdiction based on passage of
the national licensing examination, you are not an "examination" applicant.
2. Read these instructions, then read the Filing Instructions related to the method
of application under which you qualify to determine the documentation and
forms you must submit. The methods under which you may file to obtain a
license as a registered nurse are:
a. Examination
b. Endorsement
c. Restoration
3. All individuals applying for initial licensure and/or restoration as a registered
nurse in Illinois must submit to a criminal background check and provide
evidence of fingerprint processing from the Illinois State Police, or its
designated agent. See attached "Important Notice--Criminal Background
Check Requirement" for more information concerning this requirement.
Note: The Criminal Background Check Requirement does not apply to
those applicants making application for registered nurse examination/
licensure who are licensed in Illinois as a licensed practical nurse.
4. All documents in a foreign language must be accompanied by an original,
notarized translation that has been transcribed by a person other than the
applicant, who is fluent in both English and the language of the documents(s).
The translator shall certify to the above requirements as well as to the accuracy of the translation.
5. For information concerning the completion of any of the enclosed forms,
refer to the Forms Completion Guide on pages 10 and 11. You may photocopy any of the enclosed forms if additional forms are needed.
6. If needed, a telephone number for assistance in completing the Application
Package is indicated on the REFERENCE SHEET.
EXAMINATION
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
General Examination
Instructions
1. Read the above General Instructions before proceeding. All documents and
forms required for licensure by examination must be submitted to:
Continental Testing Services Inc.
P.O. Box 100
LaGrange, Illinois 60525-0100
2. Application fee payment must be in the form of a certified check or money
order made payable to Continental Testing Services, Inc. A separate examination registration fee will be paid at the actual time of registration as noted
in Chart II on the Reference Sheet. To determine the fees, see the Reference
Sheet, Chart I and II.
Registered Nurse - Page 2
EXAMINATION (cont'd)
General Examination
Instructions (cont'd)
3. Conditions of Application--Applicants have three years from the date of the
Department's receipt of the application to complete the application process
including passage of examination. If the process has not been completed in
three years, the application shall be denied, the fee forfeited, and the applicant
must reapply and meet the requirements in effect at the time of application,
including proof of the successful completion of at least 2 additional years
of professional nursing education.
NOTE: Excelsior College is an unapproved nursing education program
in the State of Illinois due to the fact that it does not have concurrent theory
and clinical components as required by the Illinois Nurse Practice Act.
Therefore, it is considered to be a correspondence course which is identified
by the Act as not meeting the requirements for licensure.
Practice Pending
Licensure
Pursuant to Public Act 95-0639, you are prohibited from practicing until such
time as you have completed and passed the Department approved licensure
examination and are in receipt of official IDFPR/CTS notification.
Practice Under
Supervision
Pursuant to 60-10(d)(e) of the Illinois Nurse Practice Act, an applicant may
practice as a license-pending registered nurse under direct supervision for a
period of three months from the official date of passing the licensure exam as
inscribed within his/her official formal pass letter. No applicant for licensure
practice under the provisions of this paragraph shall practice license-pending
except under the direction of a registered professional nurse or an advanced
practice nurse licensed under this Act. In no instance shall any such applicant
practice or be employed in any management capacity.
Educated Inside the U.S. or
one of its Territories
If you received your education in the United States or one of its territories, you
must submit the following documentation (read the General Instructions and
the General Examination Instructions on page 2 now, if you have not already
done so):
- IMPORTANT NOTICE -
The National Council of State Boards of
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing
who licensure participate in Nursys®.
Please visit Nursys.com (www.nursys.
com) or https://www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to
view a complete list.
If the state(s) where you have been licensed
as a nurse licensure participates in Nursys®,
you must request verification of your licensure
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does
not appear on the Nursys® list of licensure
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the
Illinois Board of Nursing.
a. Application for Licensure and/or Examination (four-page);
b. CT-NUR Form (Verification of Licensing Agency/Board)--Submit a verification
of licensure from the state of original licensure, current state of licensure, and
any jurisdiction in which you have actively practiced within the last 5 years.
Verification of licensure for an LPN license held in another jurisdiction within
the last 5 years will only be required if you were not subsequently licensed in
the same jurisdiction as an RN.
You must direct the appropriate licensing agency(s)/board(s) to return the
completed form directly to you to be submitted with your application.
c.
ED-NUR Form (Certificate of Education)--Form must be signed by the
Dean or Director of your nursing education program with school seal
affixed, indicating graduation from a professional nursing education program approved by the Department or have been granted a certificate of
completion of pre-licensure requirements from another U.S. jurisdiction,
OR submission of official transcripts with school seal affixed.
d. Fee--See page 2, General Examination Instructions, paragraph 2.
Registered Nurse - Page 3
EXAMINATION (cont'd)
Educated Outside the U.S.
or one of its Territories
In order to be considered for licensure, applicants who received their education
outside the United States or one of its territories must submit the following (read
the General Instructions and the General Examination Instructions on page 2 now,
if you have not yet done so):
a.
- IMPORTANT NOTICE -
Supporting Document CCA must be completed and submitted with each application. Your application will not be processed without completion of this form.
b. Application for Licensure and/or Examination (four page);
The National Council of State Boards of
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing
who licensure participate in Nursys®.
Please visit Nursys.com (www.nursys.
com) or https://www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to
view a complete list.
If the state(s) where you have been licensed
as a nurse licensure participates in Nursys®,
you must request verification of your licensure
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does
not appear on the Nursys® list of licensure
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the
Illinois Board of Nursing.
c.
CT-NUR Form (Verification of Licensing Agency/Board)--Submit a verification
of licensure from the state of original licensure, current state of licensure and
any jurisdiction in which you have actively practiced within the last 5 years.
Verification of licensure for an LPN license held in another jurisdiction within
the last 5 years will only be required if you were not subsequently licensed in
the same jurisdiction as an RN;
You must direct the appropriate licensing agency(s)/board(s) to return the completed form directly to you to be submitted with your application.
d. Submit the following proof of education:
1. A credentials evaluation report of your foreign nursing education from a
Department approved credentialing service. One such service is the Commission on Graduates of Foreign Nursing Schools (CGFNS) Credentials
Evaluation Service (CES). The required report is the Healthcare Profession & Science Course-by-Course Report. The Division will download
the credentials evaluation report from CGFNS' Web site when it becomes
available.
You may contact CGFNS Credentials Evaluation Service as follows:
Credentials Evaluation Service
CGFNS/ICHP
3600 Market Street, Suite 400
Philadelphia, PA 19104-2651
Telephone #215/349-8767
Web site: http://www.cgfns.org
Additionally, the Educational Records Evaluation Service (ERES) has been
approved by the Division as a nursing educational credentialing agency. The
required report to request is the Nursing Evaluation and Course by Course
Report. The report will be downloaded from ERES when available.
You may contact ERES as follows:
- NOTE Proof of licensure in your
country of
education shall be
required as a part of the
credentialing process.
Educational Records Evaluation Service, Inc.
601 University Avenue, Suite 127
Sacramento, CA 95825
Telephone # 916/921-0790
Email: [email protected]
Web site: http://www.eres.com
Further, if your first language is not English, you shall be required to submit certification of passage of the Test of English as a Foreign Language
(TOEFL). The minimum passing score on the paper-based test is 560. The
minimum passing score on the computer-based test is 220. The minimum
passing score on the internet-based test is 83.
Registered Nurse - Page 4
EXAMINATION (cont'd)
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
Education Outside the U.S. or one
of its Territories (cont'd)
TOEFL scores previously considered as "passing" scores will be accepted
for a period of two years from the date of passage.
e.
In lieu of the above, the educational requirement may be met by submission of
proof issuance of the following original certificates from the Commission on
Graduates of Foreign Nursing Schools (CGFNS):
CGFNS Certificate
VisaScreen Program Certificate
f.
Fee--See page 2, General Examination Instructions, paragraph 2.
ENDORSEMENT
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
General Endorsement
Instruction
1. Read the Applying for Licensure, General Instructions on page 2 be
fore proceeding. All documents and forms required for licensure
by endorsement must be submitted as a packet to:
Illinois Department of Financial and Professional Regulation
ATTN: Division of Professional Regulation
P.O. Box 7007
Springfield, IL 62791
2. Fee payment must be in the form of a check or money order made
payable to Department of Financial and Professional Regulation (see
Reference Sheet, Chart I).
NOTE: Excelsior College is an unapproved nursing education program in
the State of Illinois due to the fact that it does not have concurrent theory and
clinical components as required by the Illinois Nurse Practice Act. Therefore,
it is considered to be a correspondence course which is identified by the Act as
not meeting the requirements for licensure.
There is a provision in the Act to allow for individual review of applications
from applicants who are graduates of such programs provided the applicant is
currently licensed in another U.S. jurisdiction and has been actively practicing
in clinical nursing for a minimum of two (2) years. The applicant must have an
employer complete a VE (Verification of Employment) form verifying two full
years of clinical practice as a registered nurse. This must be submitted with
the endorsement application. When the application is complete, it is reviewed
by the Board of Nursing for a determination of eligibility to be rendered.
Registered Nurse - Page 5
ENDORSEMENT (cont'd)
Temporary Permit
In accordance with Section 60-10(f)(g) of the Illinois Nurse Practice Act, you may be eligible
to receive a temporary permit. The permit is valid for six months from the date of issuance, or
issuance of an Illinois Registered Nurse License, or notification that the Department intends to
deny licensure, whichever comes first. It will be your responsibility to complete the endorsement licensure process prior to the expiration of the temporary permit. In order to receive
the permit, submit the following forms and documentation (read the General Instructions on
Page 2 and the General Endorsement Instructions above now, if you have not yet done so):
a.
Supporting Document CCA must be completed and submitted with each
application. Your application will not be processed without completion of this
form.
- Important Notice -
b.
Application for Licensure and/or Examination (four page);
Applicants educated outside
the U.S. or its Territories must
have an acceptable credentials
evaluation report from a
Department-approved
credentials evaluation service
on file with the Department
indicating their nursing
education is comparable to an
entry-level registered
professional nursing education
program in the United States
prior to being deemed eligible
for a temporary permit.
c.
TP-NUR Form (Temporary Permit);
d.
Photostatic copies of all current active Registered/Licensed Practical Nurse licenses and/
or temporary permits/licenses held by you in any other jurisdiction(s) of the United States.
Current licensure in at least one other jurisdiction of the United States is required by
the Illinois Nursing and Advanced Practice Nursing Act;
e.
Fee--Combine the endorsement fee and the temporary permit fee into one check or
money order. (See page 5, General Endorsement Instructions, paragraph 2, for additional
information.)
f.
Proof of fingerprint submission in the form of a copy of the fingerprint receipt (for Illinois
graduates or Illinois residents), or a completed FP-NUR form for out-of-state and foreigneducated applicants.
Educated Inside U.S. or
one of its Territories
In order to be considered for licensure, applicants who were educated in the United States or
one of its territories must submit the following: (read the General Instructions on Page 2 and
the General Endorsement Instructions on page 5 now, if you have not yet done so):
a.
Supporting Document CCA must be completed and submitted with each
application. Your application will not be processed without completion of this
form.
b.
Application for Licensure and/or Examination (four page). You need not resubmit this
form if you previously applied for a temporary endorsement permit;
c.
CT-NUR Form (Verification of Licensing Agency/Board--Submit verification of licensure
from the state of original licensure, current state of licensure and any jurisdiction in which
you have actively practiced within the last 5 years. Verification of licensure for an LPN
license held in another jurisdiction within the last 5 years will only be required if you
were not subsequently licensed in the same jurisdiction as an RN. Current registration in
another state is required by the Illinois Nurse Practice Act. You must direct the licensing
agency/board to return the completed form to you to be submitted with your application.
d.
ED-NUR Form (Certificate of Education) indicating graduation from a professional nursing
education program approved by the Department; or the granting of a certificate of completion of pre-licensure requirements from another U.S. jurisdiction. The ED form must
be signed by the director of the nursing education program with the school seal affixed,
- IMPORTANT NOTICE CERTIFICATION OF LICENSURE
The National Council of State Boards of
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing
who licensure participate in Nursys®.
Please visit Nursys.com (www.nursys.
com) or https://www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to
view a complete list.
If the state(s) where you have been licensed
as a nurse licensure participates in Nursys®,
you must request verification of your licensure
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does
not appear on the Nursys® list of licensure
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the
Illinois Board of Nursing.
OR official transcripts with school seal affixed.
e.
Fee--See General Endorsement Instructions, page 5, paragraph 2.
Registered Nurse - Page 6
ENDORSEMENT (cont'd)
Educated Outside U.S. or
its Territories
- IMPORTANT NOTICE -
In order to be considered for licensure, applicants who were educated outside the United
States or one of its territories must submit the following (read the General Instructions
on Page 2 and the General Endorsement Instructions on page 5 now, if you have not
yet done so):
a.
Application for Licensure and/or Examination (four page). You need not submit
this form if you previously applied for a temporary endorsement permit;
b.
Supporting Document CCA must be completed and submitted with each application.
Your application will not be processed without completion of this form.
c.
CT-NUR Form (Verification of Licensing Agency/Board)--Submit verification
of licensure from the state of original licensure, current state of licensure and any
jurisdiction in which you have actively practiced within the last 5 years. Current
registration in another state is required by the Illinois Nursing and Advanced Practice
Nursing Act. Verification of licensure for an LPN license held in another jurisdiction
within the last 5 years will only be required if you were not subsequently licensed
in the same jurisdiction as an RN.
CERTIFICATION OF LICENSURE
The National Council of State Boards of
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing
who licensure participate in Nursys®.
Please visit Nursys.com (www.nursys.
com) or https://www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to
view a complete list.
If the state(s) where you have been licensed
as a nurse licensure participates in Nursys®,
you must request verification of your licensure
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does
not appear on the Nursys® list of licensure
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the
Illinois Board of Nursing.
You must direct the licensing agency/board to return the completed form to you to
be submitted with your application.
d.
Request the following proof of education to be prepared for and make available to
the Department:
1. A credentials evaluation report of your foreign nursing education from
a Department approved credentialing service. The credentials evaluation
report must reflect proof of licensure in the country of education. One
such service is the Commission on Graduates of Foreign Nursing Schools
(CGFNS) Credentials Evaluation Service (CES). The required report is
the Healthcare Profession & Science Course-by-Course Report. The Division
will download the credentials evaluation report from CGFNS' Web site when it
becomes available.
You may contact CGFNS Credentials Evaluation Service as follows:
Credentials Evaluation Service
CGFNS/ICHP
3600 Market Street, Suite 400
Philadelphia, PA 19104-2651
Telephone # 215/349-8767
Web site: http://www.cgfns.org
- NOTE Proof of licensure in your
country of
education shall be
required as a part of the
credentialing process.
Additionally, the Educational Records Evaluation service (ERES) has been approved
by the Division as a nursing educational credentialing agency. The required report
to request is the Nursing Evaluation and Course by Course Report. The report will
be downloaded from ERES when available.
You may contact ERES as follows:
Educational Records Evaluation Service, Inc.
601 University Avenue, Suite 127
Sacramento, CA 95825
Telephone # 916/921-0790
Email: [email protected]
Web site: http://www.eres.com
Registered Nurse - Page 7
ENDORSEMENT (cont'd)
Educated Outside U.S. or
its Territories (cont'd)
Further, if your first language is not English, you shall be required to submit certification of passage of the Test of English as a Foreign Language
(TOEFL). The minimum passing score on the paper-based test is 560. The
minimum passing score on the computer-based test is 220. The minimum
passing score on the Inter-based test is 83.
TOEFL scores previously considered as "passing" scores will be accepted
for a period of two years from the date of passage.
e. In lieu of the above, the educational requirement may be met by submission
of proof issuance of the following original certificates from the Commission
on Graduates of Foreign Nursing Schools (CGFNS):
f.
CGFNS Certificate
VisaScreen Program Certificate
Fee--See page 5, General Endorsement Instructions, paragraph 2.
RESTORATION
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
General Restoration
Instructions
Do the following if you wish to apply for the restoration of your license because
it has expired or been placed on inactive status for more than five years. Read
the General Instructions on Page 2 before proceeding. All documents and forms
required for licensure by restoration must be submitted to the following address:
Illinois Department of Financial and Professional Regulation
ATTN: Division of Professional Regulation
P.O. Box 7007
Springfield, Illinois 62791
Fee payment must be in the form of a check or money order made payable to
the Department of Financial and Professional Regulation. (See the Official Use
Only Box on supporting document RS (Restoration), for the fee amount you
must submit.)
Submit the following documents and/or forms:
a. Application for Licensure and/or Examination (four page);
b. Supporting Document CCA must be completed and submitted with each
application. Your application will not be processed without completion of
this form.
c. RS Form (Restoration)--If this form was not included in the application
packet, you must obtain one by contacting the Department of Financial and
Professional Regulation at 1-800-560-6420;
Registered Nurse - Page 8
RESTORATION
General Restoration
Instructions (cont'd)
~IMPORTANT NOTICE~
These Restoration
Instructions apply only to
those registered nurses whose
licenses have been on inactive
status, or in non-renewed
status, for five or more years.
If your license has been
inactive, or in non-renewed
status, for less than five
years, you should contact
the Department of Financial
and Professional Regulation
at 1-800-560-6420 for detailed
instructions on how to
restore it to active status.
Temporary Permit
(cont'd)
d. CT-NUR Form (Verification of Licensing Agency/Board)--Submit verification
of licensure from the state of original licensure, current state of licensure and
any jurisdiction in which you have actively practiced within the last 5 years.
Verification of licensure for an LPN license held in another jurisdiction within
the last 5 years will only be required if you were not subsequently licensed
in the same jurisdiction as an RN.You must direct the licensing agency/board
to return the completed form to you to be submitted with your application.
e. VE Form (Verification of Employment/Experience)--This form must be completed by the Personnel Representative for Nursing Services of your place of
employment and returned to the Department of Financial and Professional
Regulation, Division of Professional Regulation in a sealed envelope.
f.
DD214--If restoring after active military service, submit a copy of this form.
NOTE: If unable to provide proof of fitness to practice nursing via submission
of a VE form substantiating active engagement in nursing practice in
another U.S. jurisdiction within the last five (5) years, persons making
application for restoration of license shall be required to successfully
complete the Department-approved licensure examination (NCLEX)
prior to the restoration of their license. You must apply directly to the
Department; information to facilitate the exam process will be provided
once the application has been reviewed and evaluated by the Department.
In accordance with Section 60-25(b)(e) of the Illinois Nurse Practice Act, you
may apply for a temporary permit. The permit is valid for six (6) months from
the date of issuance, or re-issuance of a permanent license by restoration or notification that the Department intends to deny licensure, whichever comes first.
It will be your responsibility to complete the restoration process prior to the
expiration of the temporary permit. If eligible, the permit will be issued within
fourteen days of receipt of a complete application.
In order to receive the permit, submit the following forms and documentation:
a.
Application for Licensure and/or Examination (four page);
a.
Supporting Document CCA must be completed and submitted with each
application. Your application will not be processed without completion of
this form.
b.
TP-NUR form (Temporary Permit);
c.
Photostatic copies of all current active Registered/Licensed Practical
Nurse licenses and/or temporary permits/licenses held by you in any other
U.S. jurisdiction(s). Current licensure in at least one other jurisdiction of
the United States is required by the Illinois Nurse Practice Act, or
verification of employment in nursing practice within the last five years in
a United States jurisdiction;
d.
Fee--Combine the restoration fee and the temporary permit fee into one
check or money order.
Registered Nurse - Page 9
FORMS COMPLETION GUIDE
This guide will help you complete the forms needed to apply for licensure. For specific information regarding the forms
which you will be required to submit, refer to the filing instructions relative to the method of licensure under which you
are applying.
Application for Licensure
and/or Examination
Provide all applicable information requested on all four pages of the application.
The following will assist you in this endeavor.
1. Part 1--Use the Reference Sheet (Chart I) to record the appropriate Profession Name, 3 digit Profession Code, Licensure Method and Fee;
2. Part II--Enter all applicable information requested. On number 3, Social
Security Number is mandatory;
3. Part III, number 6--Itemize all university/college coursework, including
nursing education since graduation from high school. Please indicate beginning and ending dates by year;
4. Part IV--Record of Licensure Information. Individuals licensed in a U.S.
jurisdiction or a foreign country or province must state whether or not they
have ever held licensure (either permanent or temporary) to practice as a
registered nurse or licensed practical nurse;
5. Part V--You must indicate type, dates, and results for any and all nurse
examinations taken (i.e., NCLEX-RN);
6. Part VI--This part must be completed by all applicants;
7. Part VII--Graduates of Illinois Nursing Education Programs must indicate
school code in item "c." (See Reference Sheet, Chart IV.) All other applicants indicate "See ED-NUR" in the space provided for school code;
8. Part VIII--This part must be completed by all applicants;
9. Part IX--Read the certifying statement and then sign and date your application.
Registered Nurse - Page 10
FORMS COMPLETION GUIDE (cont'd)
CCA
Health Care Workers Charged
With Or Convicted Of Criminal
Acts
This Document MUST be completed and submitted with each application. Your application will not be processed without completion/receipt of this form.
CT-NUR
Verification of Licensure
This document must be completed by the licensing jurisdiction(s) of original licensure,
current state of licensure and any jurisdiction in which you have actively practiced
within the last 5 years. Verification of licensure for a previously held LPN license
within the last 5 years will only be required if you were not subsequently licensed in
the same jurisdiction as an RN.
Complete applicant section of form; then send form to each state or territory in which
you have ever held registered or practical nurse licensure. Completion of CT-NUR
form is not necessary if license is held in Illinois. Direct the licensing agency/board
to return the completed form to you and submit it with your application for licensure
and/or examination.
Copies of licenses are not
acceptable in lieu of an official
verification of licensure.
Important: The National Council of State Boards of Nursing (NCSBN) handles
verification of licensure for many state boards of nursing who licensure participate in
Nursys®. Please visit Nursys.com (www.nursys.com) or https://www.nursys.com/
NLV/LicenseVerificationJurisdictions.aspx to view a complete list.
If the state(s) where you have been licensed as a nurse licensure participates in Nursys®,
you must request verification of your licensure through Nursys® (www.nursys.com),
not the state(s). If your state(s) of licensure does not appear on the Nursys® list of
licensure participating boards of nursing, you must use the CT-NUR form (Verification
of Licensing Agency/Board) to verify your license to the Illinois Board of Nursing.
ED-NUR
Certification of Education
If you received your nursing education in the United States or one of its territories and
are applying for licensure under examination or endorsement, you must submit this
form. Complete the applicant section of this form, then send the form to the educational
institution at which you completed your registered nurse education program. The form
must be signed by the dean or director of your nursing education program with school
seal affixed. Direct the program to return the form to you and submit it with your application for licensure and/or examination.
TP-NUR
Temporary Permit
This form provides a means of applying for licensure pending the processing of an
endorsement/restoration application. The entire form is to be completed by the applicant. Failure to properly complete, sign and date this form will result in a delay in the
processing of your temporary endorsement or restoration permit.
VE
Verification of
Employment/Experience
Fill in the top portion of this form. Then submit it to your employer to be completed
by the Personnel Representative for Nursing Services. Instruct that person to fill out
the remainder of the form and return it to you for enclosure with the rest of your application. The purpose of this form is to provide proof of your active engagement in
nursing in another jurisdiction.
RS
Restoration
This is one of the forms you must complete to restore your Illinois Registered Nurse
license. The applicant is to complete the entire form and submit it with the other documentation as requested on page 7.
FP-NUR
Certifying Statement of
Fingerprint Submission
This form must be completed by all applicants for fingerprinting in the State of Illinois
unless a receipt issued by an approved fingerprint vendor is submitted.
Registered Nurse - Page 11
LICENSURE METHODS AND DEFINITIONS
Following are definitions of the various methods used in issuing licenses for professionals in the
State of Illinois. Some of these licensure methods may not be applicable to your profession. Refer
to the enclosed instruction sheet to determine the specific licensure methods/requirements for
your profession.
Licensure Methods
Definition
Examination
Applicant has applied or is required to take and pass all
or a portion of an exam scheduled and/or given by the
Department or a representative of the Department.
Endorsement of License
Original license issued in another state and that state's
requirements were substantially equivalent to Illinois
requirements at time license was issued.
Acceptance of Examination
Applicant has taken a National Exam, referred to by
Illinois statute, in any state. Applicant may or may not be
licensed in another state.
Restoration
Applicant has previously been licensed in State of Illinois
and has allowed license to lapse long enough to require
reapplication. Possible exam passage and/or committee
review.
Grandfather/Waiver
Applicant will be licensed without regard to current
requirements because statute allows this based on past
qualification and practices (for a specified time only).
Non-examination
Applicant is licensed by meeting qualifications required
by statute. There is no exam for these professions.
These can be either businesses or individuals.
DPR-I-DEFINE D 7/06
IMPORTANT NOTICE
Elder and Child Abuse Reporting
"Pursuant to Public Act 91-0244, effective January 1, 2000, if you have
reason to believe that an adult 60 years of age or older who resides
in a domestic living situation who, because of dysfunction is unable
to seek assistance for himself or herself has, within the previous 12
months been subject to abuse, neglect or financial exploitation, the
mandated reporter shall, within 24 hours after developing such belief,
report this suspicion to the Department on Aging. Reports should be
made to DEPARTMENT ON AGING AT 1-800-252-8966."
_____________________________________
"Public Act 91-0244 also requires that if you have reasonable cause
to believe a child known to you in your professional capacity may be
an abused or neglected child you are required to report such possible
neglect or abuse to the DEPARTMENT OF CHILDREN AND FAMILY
SERVICES AT 1-800-25abuse."
DPR-I-abuse 12/99
REFERENCE SHEET
ALL FEES ARE NONREFUNDABLE
Department reserves the right to change examination dates, filing deadlines and fees
if prevailing circumstances necessitate such action.
CHART I - PROFESSION NAME, PROFESSION CODE, LICENSURE METHOD & FEE
Profession Name
Profession
Code
Licensure
Method
Application
Fee
Registered Nurse
041
Examination (CTS)
Examination (NCSBN)
$98.00
$200.00
Registered Nurse
041
Endorsement of License
Temporary Permit
$50.00
$25.00
RegIstered Nurse
041
Restoration
Temporary Permit
See Supporting Document RS
$25.00
CHART II - EXAMINATION CODES AND FEES
Since the application for examination is a dual process, you must:
Complete the Department's licensure/examination application by applying online at www.continentaltesting.net
and pay the required administration fee as noted above; and
Register for the examination through the NCLEX Examination website at www.ncsbn.org/nclex.htm.
Once you have completed both processes and are determined eligible you will receive:
An Authorization to Test (ATT) that will contain the necessary information to schedule yourself for this examination.
The ATT eligibility lasts for 90 days only. You must take the examination within those 90 days or reapply with new
fees to CTS and Pearson Vue.
CHART III - EXAMINATION DATES - Information will be available once you are approved for the exam.
* * * * * REQUEST FOR ASSISTANCE * * * * *
If assistance is needed, direct your request (based upon your licensure method) to:
Licensure Methods Except Examination (US ONLY)
1-800-560-6420
Examination Licensure Method Only
TTY
1-866-325-4949
1-708-354-9911
Please allow 6 weeks from mailing your application
before making an inquiry concerning its status.
SEE REVERSE SIDE FOR CHART IV - SCHOOL CODES
DPR-RN 10/14
Reference Sheet - Page 1 of 2
CHART IV - SCHOOL CODES
ILLINOIS NURSING EDUCATION PROGRAMS - PROGRAMS PREPARING REGISTERED NURSES
AURORA
US49508100
Aurora University
BELLEVILLE
US49405500
Southwestern Illinois College
BLOOMINGTON
US49501100
Ill Wesleyan Univ
BOURBONNAIS
US49505000
Olivet Nazarene University
CANTON
US49305100
Graham Hospital
US49400200
Spoon River College
CARTERVILLE
US49404200
John A. Logan College
CENTRALIA
US49408600
Kaskaskia College
CHAMPAIGN
US49405200
Parkland College
CHICAGO
US49508200
Chicago State University
US49501000
DePaul University
US49408800
Kennedy-King College
US49508600
Loyola University
US49405300
Malcolm X College
US49509800
North Park University
US49405400
Olive-Harvey College
US49407700
Richard J. Daley College
US49400000
Robert Morris College
US49501600
Rush University
US49503000
Rush University Master's Entry
US49508400
St. Xavier University
US49401600
Truman College
US49501400
University of Illinois
US49502600
University of Illinois at Chicago--MSN
CHICAGO HTS.
US49406200
Prairie State College
CICERO
US49408700
Morton College
CRYSTAL LAKE
US49401000
McHenry County College
DANVILLE
US49500400
Lakeview College of Nursing
US49402300
Danville Area Community College
DE KALB
US49505900
Northern Illinois University
DECATUR
US49505800
Millikin University
US49403200
Richland Comm. College
DES PLAINES
US49405000
Oakton Community College
DIXON
US49405100
Sauk Valley College
EDWARDSVILLE
US49501300
Southern Illinois University
ELGIN
US49409200
Elgin Community College
ELMHURST
US49509100
Elmhurst College
FREEPORT
US49407000
Highland Community College
GALESBURG
US49408500
Carl Sandburg College
GLEN ELLYN
US49409500
College of DuPage
GODFREY
US49408300
Lewis & Clark Community College
DPR-RN 10/14
GRAYSLAKE
US49409000
College of Lake County
HARRISBURG
US49404400
Southeastern Illinois College
INA
US49404100
Rend Lake College
JACKSONVILLE
US49507800
MacMurray College
JOLIET
US49500300
University of St. Francis
College of Nursing and Allied Health
US49409900
Joliet Junior College
KANKAKEE
US49409600
Kankakee Community College
MACOMB
US49502300
Western Illinois University
MALTA
US49407600
Kishwaukee College
MATTOON
US49400100
Lake Land College
MOLINE
US49403300
Black Hawk College
US49404000
Trinity College of Nursing (ADN)
NORMAL
US49403400
Heartland Comm. College
US49505600
Mennonite College of Nursing
at Illinois State University
OAK PARK
US49505700
Concordia / Resurrection University
OGLESBY
US49405800
Illinois Valley Comm College
OLNEY
US49406600
Ill Eastern Comm Colleges
PALATINE
US49405600
Wm Rainey Harper College
PALOS HEIGHTS
US49508000
Trinity Christian College
PALOS HILLS
US49408400
Morraine Valley Comm College
PEORIA
US49500200
St. Francis Md. Ctr. Coll. Nsg.
US49504900
Bradley University
US49409700
Illinois Central College--East Peoria
US49506000
Methodist Medical Center College of
Nursing
QUINCY
US49504100
Blessing Riemer/Culver Stockton College
US49403100
John Wood Comm. College
RIVER GROVE
US49400600
Triton College
ROCKFORD
US49500500
Rockford College
US49500600
St. Anthony College of Nursing
US49405700
Rock Valley College
ROMEOVILLE
US49508300
Lewis University
SOUTH HOLLAND
US49406700
South Suburban College
SPRINGFIELD
US49500700
St. John's College
US49408000
Lincoln Land Community Coll.
SUGAR GROVE
US49408900
Waubonsee Comm College
ULLIN
US49404300
Shawnee Community College
Reference Sheet - Page 2 of 2
Illinois Department of Financial and Professional Regulation
Division of Professional Regulation
Application Checklist for Registered Nurses
In order for your application to be processed,
ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
Before you mail your application, check the following items to make sure your application is complete!
FOUR-PAGE APPLICATION REVIEW
Part I.
Application Category Information
Part II.
Applicant Identifying Information
Part III.
Education Information
Part IV.
Record of Licensure Information
Part V.
Record of Examination
Part VI.
Personal History Information
Part VII.
Examination Coding Information (if applicable)
Part VIII.
Child Support and/or Student Loan Information
Part IX.
Certifying Statement--Signed and Dated
SUPPORTING DOCUMENTS
COMPLETED
SUBMITTED
Application Fee - $50 application fee; $25 temporary permit fee; $75 total
Supporting Document CCA must be completed and submitted with each application.
Your application will not be processed without completion of this form.
ED-NUR Form with seal and signature affixed; or
Nursing transcripts with seal affixed.
CGFNS or CES Report
CT-NUR (Certification of Licensure) Form completed by state of original licensure and
any state in which you have practiced in the last five (5) years.
Verification requested from NURSYS (if applicable)
VE (Verification of Employment) Form (if applicable)
Proof of Name Change (if applicable)
Criminal Background Check Requested
Proof of Fingerprint Submission
TP-NUR Form (if applicable)
Copies of All Active Licenses (temporary permit only)
RS (Restoration) Form (if applicable). You must obtain this form by contacting the
Department at 1-800-560-6420.
Current NCLEX exam passage (if applicable)
All supporting documents may not be required. Please refer to application instructionsfor your specific method of licensure.
IL486-1971 (RN) 2/15
FOR OFFICIAL USE ONLY
APPLICATION FOR
LICENSURE AND/OR EXAMINATION
IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure
under 225 of the Illinois Compiled Statutes. Disclosure of this information is VOLUNTARY.
However, failure to comply may result in this form not being processed.
The following materials are required to make Application for
Licensure and/or Examination in Illinois:
Carefully follow all steps outlined on the INSTRUCTION SHEET. In
addition, note the following:
1.
A. Type or print legibly with black ink only.
Four page APPLICATION FOR LICENSURE AND/OR
EXAMINATION.
2. INSTRUCTION SHEET, which gives step by step application instructions for your profession.
3. REFERENCE SHEET, which gives detailed coding
information for your profession.
4. SUPPORTING DOCUMENTS, forms, and/or any other
documentation you may be required to submit with
your application.
5. If the name shown on your supporting documents is different from that shown on your application, you must submit
PROOF OF LEGAL NAME change - copy of marriage
license, divorce decree, affidavit or court order.
PART I: Application Category Information
B. FEES ARE NOT REFUNDABLE.
C. Disclosure of your U.S. social security number, if you have one, is
mandatory, in accordance with 5 Illinois Compiled Statutes 100/10-65
to obtain a license. The social security number may be provided to
the Illinois Department of Public Aid to identify persons who are more
than 30 days delinquent in complying with a child support order, or
to the Illinois Department of Revenue to identify persons who have
failed to file a tax return, pay tax, penalty or interest shown in a filed
return, or to pay any final assessment or tax penalty or interest, as
required by any tax Act administered by the Illinois Department of
Revenue, or to other entities for verification of identification.
A. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4
3. LICENSURE METHOD
1. PROFESSION NAME
2. PROFESSION CODE
4. FEE
$
B. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION
This is the first time I have made application for this
profession in Illinois.
My application for this profession had previously been denied
in Illinois. I am reapplying since I have fulfilled additional
requirements.
I have previously made application for this profession in
Illinois. However, my previous application expired and I
am now reapplying.
I have previously made application for this profession in
Illinois. However, I am now applying under new statutory
language.
Other:
PART II:
1. NAME
Applicant Identifying Information--You must notify the Department of Financial and Professional Regulation Division of Professional Regulation and/or Continental Testing Service in writing, of any address changes after you
file this application in order to receive any further information.
LAST
FIRST
4. PERMANENT MAILING ADDRESS
5. BUSINESS ADDRESS
MIDDLE
STREET
STREET
2. TITLE (e.g., M.D., D.D.S., etc.)
CITY
STATE/COUNTRY
ZIP CODE
COUNTY
CITY
STATE/COUNTRY
ZIP CODE
COUNTY
6. MAIDEN, GIVEN SURNAME, OR ANY NAME(S) UNDER WHICH SUPPORTING
DOCUMENTS WILL BE SUBMITTED. (SEE INSTRUCTIONS #5 ABOVE)
8. PLACE OF BIRTH
CITY
3. UNITED STATES SOCIAL SECURITY NO.
STATE/COUNTRY
7. MOTHER'S MAIDEN NAME
10. AGE
9. DATE OF BIRTH
Month
Day
Year
11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED
__
Work: ( __ __ __ ) __ __ __ __ __ __ __
__
Home: ( __ __ __ ) __ __ __ __ __ __ __
(Area Code)
Fax:
( __ __ __ ) __ __ __ __ __ __ __
IL486-1019 01/14 (LT)
12. PREFERRED e-MAIL
ADDRESS(ES) [If available]
(Area Code)
__
(Area Code)
Female
Male
Fax:
( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code)
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4
Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.com.
1. PRELIMINARY EDUCATION (Elementary and High School or G.E.D. Circle number of years completed)
1 2 3 4 5 6 7 8 9 10 11 12
2. NAME OF LAST PRELIMINARY SCHOOL
ATTENDED
Graduated
High School?
Yes
Received
OR G.E.D.?
No
3. LAST PRELIMINARY SCHOOL LOCATION
(City and State)
Yes
No
4. DATE OF GRADUATION
Month
Year
5. COLLEGE OR UNIVERSITY (Circle number of years completed)
1 2 3 4 5 6 7 8
6. COLLEGE OR UNIVERSITY NAME
(Undergraduate and Graduate)
Graduated?
Yes
LOCATION
(City and State or Country)
No
DATES OF ATTENDANCE
FROM
TO
Month/Year
Month/Year
7. SPECIALIZED TRAINING (Residency, Professional Training, Vocational Training, Practical or Clinical Training)
DATES OF ATTENDANCE
LOCATION
INSTITUTION NAME
(City and State or Country)
TO
FROM
Month/Year
IL486-1019
TYPE OF
DEGREE EARNED
Did You Complete
Training?
Month/Year
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 2 of 4
NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________
PART III: Education Information
If you have ever been licensed to practice the profession for which you are now making application, or held a related license, complete
the information requested below. If you have ever held a temporary, trainee or apprenticeship license, or a permit, it must be listed here
also. In addition, the INSTRUCTION SHEET enclosed with this Application package may instruct you to have Certification(s) of Licensure in other state(s) prepared and submitted in support of your application (contact other state(s) regarding possible fee). You must
also list all other licenses held in Illinois, however, certification of licensure from Illinois is not required. Failure to disclose all licenses
held may result in denial of your application or other appropriate action.
STATE
PROFESSION NAME
LICENSE NUMBER
DATE OF
ISSUANCE
LICENSE STATUS
(Active, Lapsed, etc.)
State of Original Licensure
State of Current Licensure where you
most recently have been practicing.
Other States of Licensure
(If additional space is needed, attach a separate sheet.)
PART V: Record of Examination
If you have ever taken a licensure examination in Illinois or any other state for the profession for which you are now making
application, you must complete the information requested below. EACH EXAMINATION ATTEMPT MUST BE SHOWN.
Failure to disclose an examination attempt may result in the denial of your application or other appropriate action.
NAME OF EXAMINATION
STATE
MONTH/YEAR
EXAM RESULTS
(Passed, Failed, Absent)
(If additional space is needed, attach a separate sheet.)
IL486-1019
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 3 of 4
NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________
PART IV: Record of Licensure Information
YES NO
1. Have you been convicted of or pled guilty or nolo contendere to any criminal offense in any state or in federal court? Please do not give
details on minor traffic charges, but do include information relating to Driving While Intoxicated (DWI) charges. If yes, attach a certified
copy of the court records regarding your conviction, the nature of the offense and date of discharge, if applicable, as well as a statement
from the probation or parole office.
2. Have you been convicted of a felony?
3. If yes, have you been issued a Certificate of Relief from Disabilities by the Prisoner Review Board? If yes, attach a copy of the certificate.
4. Have you had or do you now have any disease or condition that interferes with your ability to perform the essential functions of your profession, including any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease
or condition; (2) alcohol or other substance abuse; (3) physical disease or condition, that presently interferes with your ability to practice
your profession? If yes, attach a detailed statement, including an explanation whether or not you are currently under treatment.
5. Have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license or permit
disciplined in any way by any licensing authority in Illinois or elsewhere? If yes, attach a detailed explanation.
6. Have you ever been discharged other than honorably from the armed service or from a city, county, state or federal position? If yes, attach
a detailed explanation.
PART VII: Examination Coding Information (This part is for examination applicants only)
Refer to the REFERENCE SHEET enclosed with this application package and complete the following:
a) CHART II -
Select examination(s) you desire
and enter Test Codes.
b) CHART III -
Select the examination site you desire and enter Test Center Code:
c) CHART IV -
Find your School of Graduation and enter school code:
d) Record the number of times you have taken this exam in Illinois or any other state:
PART VIII: Child Support and/or Student Loan Information (Every applicant is required by law to respond to the
following questions)
1.
In accordance with 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's
Social Security number, and the licensee shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying
with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to
contempt of court.
Are you more than 30 days delinquent in complying with a child support order?
(NOTE: If you are not subject to a child support order, answer "no.")
2.
Yes
No
In accordance with 20 Illinois Compiled Statutes 2105/2105-(5), "The Department shall deny any license or renewal authorized by the Civil
Administrative Code of Illinois to any person who has defaulted on an educational loan or scholarship provided by or guaranteed by the Illinois
Student Assistance Commission or any governmental agency of this State; however, the Department may issue a license or renewal if the
aforementioned persons have established a satisfactory repayment record as determined by the Illinois Student Assistance Commission or other
appropriate governmental agency of this State." (Proof of a satisfactory repayment record must be submitted.)
Are you in default on an educational loan or scholarship provided/guaranteed by the Illinois
Student Assistance Commission or other governmental agency of this State?
PART IX:
Yes
No
Certifying Statement
Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me
in connection therewith, and to the best of my knowledge, they are true, correct, and complete.
Signature of Applicant
Date
I UNDERSTAND THAT FEES ARE NOT REFUNDABLE. My signature above authorizes the Department of Financial and Professional
Regulation to reduce the amount of this check if the amount submitted is not correct. I understand this will be done only if the amount
submitted is greater than the required fee hereunder, but in no event shall such reduction be made in an amount greater than $50.
IL486-1019
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 4 of 4
NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________
PART VI: Personal History Information (This part must be completed by all applicants)
IMPORTANT NOTICE: Completion of
this form is necessary to accomplish the
requirements outlined in 225 of the Illinois
Compiled Statutes. Disclosure of this
information is VOLUNTARY. However,
failure to comply may result in this form not
being processed.
1. NAME
LAST
SUPPORTING DOCUMENT
HEALTH CARE WORKERS
CHARGED WITH OR CONVICTED
OF CRIMINAL ACTS
FIRST
MIDDLE
CCA
3. PROFESSIONAL LICENSE NUMBER (if any)
__ __ __ - __ __ __ __ __ __
2. ADDRESS
STREET,
CITY,
STATE,
ZIP CODE
4. SOCIAL SECURITY NUMBER
__ __ __ - __ __ - __ __ __ __
Pursuant to 20ILCS 2105-165(a), the Department requires the following professionals to disclose information regarding
convictions pertaining to certain offenses. Please check applicable profession.
Acupuncturists
Advanced Practice Nurses
Athletic Trainers
Audiologists
Clinical Psychologists
Clinical Social Workers
Dental Hygienists
Dentists
Genetic Counselors
Licensed Clinical Professional
Counselors
Licensed Practical Nurses
Licensed Social Workers
Marriage and Family Therapists
Physician Assistants
Podiatrists
Professional Counselors
Prosthetists
Registered Nurses
Registered Surgical Assistants
Registered Surgical Technologists
Respiratory Care Practitioners
Speech Pathologists
Naprapaths
Nursing Home Administrators
Occupational Therapists
Occupational Therapy Assistants
Optometrists
Orthotists
Pedorthists
Perfusionists
Pharmacists
Physical Therapists
Physical Therapy Assistants
Physicians, including Medical Doctors (M.D.), Doctors
of Osteopathic Medicine (D.O.), and Chiropractic
Physicians (D.C.)
Any other license issued by the Department under the Acts listed in this Section and the Controlled Substances Act [740
ILCS 40], except for pharmacy technicians, issued to a person subject to the Code and this Part.
In order for your application to be evaluated, you must respond to each of the following questions:
Yes
1)
Are you currently charged with or have you been convicted of a criminal act that requires registration
under the Sex Offender Registration Act? *
2)
Are you currently charged with or have you been convicted of a criminal battery against any patient in the
course of patient care or treatment, including any offense based on sexual conduct or sexual penetration?
3)
Are you required, as part of a criminal sentence, to register under the Sex Offender Registration Act? *
4)
Are you currently charged with or have you been convicted of a forcible felony? *
No
If YES to any of the above, attach a certified copy of the court records regarding your conviction, the nature of the offense
and date of discharge, if applicable, as well as a statement from the probation or parole office.
Certification Statement
Under penalties of perjury, I declare that I have examined this Form and all supporting documents and/or information
submitted by me in connection therewith, and to the best of my knowledge, they are true, correct, and complete.
Signature of Applicant
IL486-2034 02/13 (crimacts)
Date
Page 1of 3
* DEFINITIONS
730 ILCS 150 et. seq:—Acts that require Sex Offender Registration:
(B) As used in this Article, “sex offense” means:
(1) A violation of any of the following Sections of the Criminal Code of 1961:
11-20.1 (child pornography),
11-20.3 (aggravated child pornography),
11-6 (indecent solicitation of a child),
11-9.1 (sexual exploitation of a child),
11-9.2 (custodial sexual misconduct),
11-9.5 (sexual misconduct with a person with a disability),
11-15.1 (soliciting for a juvenile prostitute),
11-18.1 (patronizing a juvenile prostitute),
11-17.1 (keeping a place of juvenile prostitution),
11-19.1 (juvenile pimping),
11-19.2 (exploitation of a child),
11-25 (grooming),
11-26 (traveling to meet a minor),
12-13 (criminal sexual assault),
12-14 (aggravated criminal sexual assault),
12-14.1 (predatory criminal sexual assault of a child),
12-15 (criminal sexual abuse),
12-16 (aggravated criminal sexual abuse),
12-33 (ritualized abuse of a child).
An attempt to commit any of these offenses.
(1.5) A violation of any of the following Sections of the Criminal Code of 1961, when the victim is a person under 18 years of age, the
defendant is not a parent of the victim, the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act, and the offense was committed on or after January 1, 1996:
10-1 (kidnapping),
10-2 (aggravated kidnapping),
10-3 (unlawful restraint),
10-3.1 (aggravated unlawful restraint).
(1.6) First degree murder under Section 9-1 of the Criminal Code of 1961, when the victim was a person under 18 years of age and
the defendant was at least 17 years of age at the time of the commission of the offense, provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.
(1.7) (Blank).
(1.8) A violation or attempted violation of Section 11-11 (sexual relations within families) of the Criminal Code of 1961, and the offense
was committed on or after June 1, 1997.
(1.9) Child abduction under paragraph (10) of subsection (b) of Section 105 of the Criminal Code of 1961 committed by luring or attempting to lure a child under the age of 16 into a motor vehicle, building, house trailer, or dwelling place without the consent of the
parent or lawful custodian of the child for other than a lawful purpose and the offense was committed on or after January 1, 1998,
provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.
(1.10) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed
on or after July 1, 1999:
10-4 (forcible detention, if the victim is under 18 years of age), provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act,
11-6.5 (indecent solicitation of an adult),
11-15 (soliciting for a prostitute, if the victim is under 18 years of age),
11-16 (pandering, if the victim is under 18 years of age),
11-18 (patronizing a prostitute, if the victim is under 18 years of age),
11-19 (pimping, if the victim is under 18 years of age).
(1.11) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed
on or after August 22, 2002:
11-9 (public indecency for a third or subsequent conviction).
(1.12) A violation or attempted violation of Section 5.1 of the Wrongs to Children Act (permitting sexual abuse) when the offense was
committed on or after August 22, 2002.
(2) A violation of any former law of this State substantially equivalent to any offense listed in subsection (B) of this Section.
(C) A conviction for an offense of federal law, Uniform Code of Military Justice, or the law of another state or a foreign country that is
substantially equivalent to any offense listed in subsections (B), (C), (E), and (E5) of this Section shall constitute a conviction for
the purpose of this Article.
IL486-2034 02/13 (crimacts)
Page 2 of 3
* DEFINITIONS
A “forcible felony”, for the purposes of Section 2105-165 of the Code (section numbers are from
the Criminal Code of 1961 [720 ILCS 5]) and 68 Illinois Administrative Code 1130.120 is one or
more of the following offenses:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
n)
o)
p)
q)
r)
s)
t)
u)
v)
w)
x)
y)
z)
aa)
bb)
cc)
dd)
ee)
ff)
gg)
hh)
ii)
jj)
kk)
First Degree Murder (Section 9-1);
Intentional Homicide of an Unborn Child (Section 9-1.2);
Second Degree Murder (Section 9-2);
Voluntary Manslaughter of an Unborn Child (Section 9-2.1);
Drug-induced Homicide (Section 9-3.3);
Kidnapping (Section 10-1);
Aggravated Kidnapping (Section 10-2);
Unlawful Restraint (Section 10-3);
Aggravated Unlawful Restraint (Section 10-3.1);
Forcible Detention (Section 10-4);
Involuntary Servitude (Section 10-9(b));
Involuntary Sexual Servitude of a Minor (Section 10-9(c));
Trafficking in Persons (Section 10-9(d));
Criminal Sexual Assault (Section 11-1.20);
Aggravated Criminal Sexual Assault (Section 11-1.30);
Predatory Criminal Sexual Assault of a Child (Section 11-1.40);
Criminal Sexual Abuse (Section 11-1.50);
Aggravated Criminal Sexual Abuse (Section 11-1.60);
Aggravated Battery (Section 12-3.05);
Compelling Organization Membership of Persons (Section 12-6.5);
Compelling Confession or Information by Force or Threat (Section 12-7);
Home Invasion (Section 12-11);
Robbery (Section 18-1);
Armed Robbery (Section 18-2);
Vehicular Hijacking (Section 18-3);
Aggravated Vehicular Hijacking (Section 18-4);
Aggravated Robbery (Section 18-5);
Terrorism (Section 29D-14.9);
Causing a Catastrophe (Section 29D-15.1);
Possession of a Deadly Substance (Section 29D-15.2);
Making a Terrorist Threat (Section 29D-20);
Falsely Making a Terrorist Threat (Section 29D-25);
Material Support for Terrorism (Section 29D-29.9);
Hindering Prosecution of Terrorism (Section 29D-35);
Boarding or Attempting to Board an Aircraft with Weapon (Section 29D-35.1);
Armed Violence (Section 33A-2); and
Attempt (Section 8-4) of any of the above specified offenses.
IL486-2034 02/13 (crimacts)
Page 3 of 3
IMPORTANT NOTICE: Completion of this
form is necessary for consideration for
licensure under 225 ILCS 65/1 et.seq. of
(Illinois Compiled Statutes). Disclosure of this
information is VOLUNTARY. However, failure
to comply may result in this form not being
processed.
SUPPORTING DOCUMENT
VERIFICATION BY LICENSING
AGENCY/BOARD
CT-NUR
APPLICANT: Complete the applicant section of this form then forward this form to the state or territory in which
you are requesting verification of your examination status, license or examination scores. Contact
certifying jurisdiction for appropriate fee. Photocopying this form is permissible.
1.
NAME
LAST
FIRST
MIDDLE
2.
DATE OF BIRTH
3.
SOCIAL SECURITY NUMBER
__ __ / __ __ / __ __ __ __
Month
4.
ADDRESS STREET, CITY, STATE, ZIP CODE
6.
MAIDEN OR GIVEN SURNAME
5.
Day
Year
REFER TO REFERENCE SHEET. Record profession name and three
digit profession code for which you are making Illinois application.
Profession Code
Profession Name
7.
APPLICANT TELEPHONE NUMBER (Daytime)
Area Code (
7a. RECORD PROFESSION NAME AS IT APPEARS ON YOUR LICENSE
FROM THE JURISDICTION TO WHICH THIS FORM IS BEING FORWARDED.
(If applicable)
)
7b. LICENSE NUMBER
(If applicable)
I hereby authorize
7c. ISSUANCE DATE OF LICENSE
(If applicable)
to furnish to the Illinois Department of
Name of Licensing Agency or Board
Financial and Professional Regulation or its designated testing service, the information requested below.
Signature
Date
LICENSING AGENCY:
RETURN COMPLETED FORM TO APPLICANT
Complete the remainder of this form. Use Part V on the reverse side of this form for any
additional information relating to the examination status of the above-named applicant
which has not been provided on this form (i.e. wrote the National State Board Test Pool
Examination, etc.) Please record N/A in areas which are not applicable.
PART I. - VERIFICATION OF EXAMINATION STATUS
A. The applicant
has written the following examination
times.
is scheduled for the following examination on __ __ / __ __ / __ __ __ __
Month
NAME OF EXAMINATION
DATE OF
EXAMINATION
RESULTS
Passed
Failed
Day
Year
DATE OF
EXAMINATION
RESULTS
Passed
Failed
National Council Licensure Examination
for Registered Nurses (NCLEX-RN)
National Council Licensure Examination
for Practical Nurses (NCLEX-PN)
B. Nursing Education Program Completed.
Name of Program
Location of Program
C. Does your state require the Council of Graduates of Foreign Nursing Schools Examination for
those Registered Nurses who received their nursing education outside the United States?
IL486-0307 04/06 (NS)
Year of Graduation
Yes
No
CT-NUR - Verification by Licensing Agency/Board - Page 1 of 2
B. LICENSE NUMBER
C. ISSUANCE DATE OF LICENSE
D. EXPIRATION DATE OF LICENSE
E. LICENSURE METHOD
Examination - Date
National Council
Licensure Examination
State Constructed
Other (Name)
F.
Endorsement of License (State)
Acceptance of Examination Results
Administered in Another State
Waiver/Grandfather
Other (Describe)
CURRENT LICENSURE STATUS
Active
Inactive
Lapsed
Other (explain)
PART III. - VERIFICATION OF EXAMINATION SCORES
A. National
N.S.B.T.P.E.
RESULTS
LPN
REGISTERED NURSE
MEDICAL
NURSING
PSYCHIATRIC
NURSING
OBSTETRIC
NURSING
SURGICAL
NURSING
NURSING OF
CHILDREN
NCLEX/COMP.
EXAM
NCLEX/COMP.
EXAM
Standard Scores
Series/Form No.
B. State Constructed Examination
Registered Nurse
SUBJECT
SCORE
Licensed Practical Nurse
SUBJECT
SCORE
PART IV. - FORMAL ACTIONS
A. Is there now or has there ever been any formal action commenced against the applicant?
Yes
No
B. Have there ever been any formal sanctions imposed against the applicant as a matter of public
record including but not limited to fine, reprimand, probation, censure, revocation, suspension,
surrender, restriction or limitation? (If yes, attach a certified copy of disciplinary action.)
Yes
No
PART V. - ADDITIONAL INFORMATION
I certify that the information contained herein is true and correct according to the official records of the State.
Print Name
SEAL
Title
Signature
Agency/Board Street Address
Date
Area Code (
City, State, ZIP Code
)
Telephone Number
Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT.
Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.
IL486-0307 04/06 (NS)
CT-NUR - Verification by Licensing Agency/Board - Page 2 of 2
NAME (Last, First, MI): _____________________________________________ SS#: _____________________ Profession: ___________________
PART II. - VERIFICATION OF LICENSURE
A. NAME OF PROFESSION AS IT APPEARS ON LICENSE
IMPORTANT NOTICE: Completion of this
form is necessary for consideration for
licensure under 225 ILCS 65/1 et.seq. of
(Illinois Compiled Statutes). Disclosure of
this information is VOLUNTARY. However,
failure to comply may result in this form not
being processed.
APPLICANT:
1. NAME
SUPPORTING DOCUMENT
ED-NUR
CERTIFICATION OF EDUCATION
Complete the applicant section of this form, then forward it to the school for completion of the
remainder of the form.
LAST
FIRST
MIDDLE
2. DATE OF BIRTH
3. SOCIAL SECURITY NUMBER
__ __ / __ __ / __ __ __ __
4. ADDRESS
STREET
CITY
STATE
ZIP CODE
Month
Day
Year
5. REFER TO REFERENCE SHEET. Record profession name and three
digit profession code for which you are making Illinois application.
6. MAIDEN OR GIVEN SURNAME
Profession Name
7. NAME OF INSTITUTION ATTENDED
Profession Code
8. DATE OF GRADUATION/COMPLETION
__ __ / __ __ / __ __ __ __
Month
Day
Year
I hereby authorize a school official of the institution named above to furnish to the Illinois Department of Financial and
Professional Regulation or its designated testing service the information requested below.
Date
SCHOOL OFFICIAL:
Signature of Applicant
Complete the bottom portion of this page and the reverse side, then return to the
applicant.
A. NAME OF INSTITUTION
B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE
C. DEPARTMENT OF INSTITUTION
D. MAJOR AREA OF STUDY OF THE APPLICANT
E. DATES OF ATTENDANCE
From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __
F.
Total academic years attended
OR
Total calendar years attended
Years
Months
Days
Years Months
Days
H. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS
WERE MET
__ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
G. TYPE OF DEGREE OR CERTIFICATE AWARDED (e.g., BA., MA.,
Ph.D.)
I. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED
__ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
J. IF EDUCATION PROGRAM WAS COMPLETED IN LESS THAN THE NORMALLY REQUIRED TIME, PLEASE EXPLAIN:
IL486-1031 05/14 (NS)
ED-NUR - Certification of Education - Page 1 of 2
NCSBN Number
SUBMISSION OF THIS FORM PRIOR TO PROGRAM COMPLETION WILL RESULT IN ITS RETURN TO THE
PROGRAM FOR CORRECTION.
I certify that the educational information recorded herein is true and correct according to the official records of this
institution.
Print Name of Dean or Director of Nursing
License Number
Signature of Dean or Director of Nursing
Date
Title
SCHOOL SEAL OR NOTARY SEAL
NOTE: If the institution does not have a school seal, this form must be notarized.
Subscribed and sworn before me this ______day of_________________, 20____.
Date of Expiration
Signature of Notary Public
RETURN THIS FORM TO APPLICANT
IL486-1031 05/14 (NS)
ED-NUR - Certification of Education - Page 2 of 2
NAME (Last, First, MI): ______________________________________________ SS#: _____________________ Profession: ___________________
K. NURSING SCHOOL PROGRAM CODE
SUPPORTING DOCUMENT
IMPORTANT NOTICE: Completion of
this form is necessary to accomplish the
requirements outlined in 225 of the Illinois
Compiled Statutes. Disclosure of this
information is VOLUNTARY. However,
failure to comply may result in this form not
being processed.
VERIFICATION OF
EMPLOYMENT / EXPERIENCE
VE
APPLICANT: Complete the application section of this form, then forward it to your employer. Upon receipt of the
completed form from the employer, include it with your Application for Licensure/Examination. You
are authorized to photocopy this form as necessary.
1. NAME
LAST
FIRST
MIDDLE
3. SOCIAL SECURITY NUMBER
2. DATE OF BIRTH
__ __ __ - __ __ - __ __ __ __
__ __ / __ __ / __ __ __ __
Month
4. ADDRESS
STREET,
CITY,
STATE,
ZIP CODE
Day
Year
5. REFER TO REFERENCE SHEET. Record profession name and
three digit profession code for which you are making Illinois application.
___ ___ ___
Profession Code
Profession Name
6. MAIDEN OR GIVEN SURNAME
7. JOB TITLE OR POSITION APPLICANT HELD
8. DATES OF EMPLOYMENT
9. SUPERVISOR NAME
From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __
Month
Day
EMPLOYER:
Year
Month
Day
Year
Complete the remainder of this form. Return the completed form to the applicant in a sealed
envelope.
PART I - EMPLOYMENT INFORMATION
A. EMPLOYER NAME
B. BUSINESS / INSTITUTION NAME
C. EMPLOYER REGISTRATION/LICENSE NUMBER
D. STATE OF EMPLOYER
REGISTRATION/LICENSE
E. BUSINESS ADDRESS
F. BUSINESS REGISTRATION/LICENSE NUMBER (If Applicable)
G. STATE OF BUSINESS
REGISTRATION/LICENSE
H. BUSINESS TELEPHONE NUMBER
STREET
CITY
STATE
ZIP CODE
Area Code (___ ___ ___) ___ ___ ___ _ ___ ___ ___ ___
PART II - APPLICANT EMPLOYMENT INFORMATION
A. NUMBER OF HOURS WORKED
PER WEEK
B. TYPE OF EMPLOYMENT
[ ]Full-time
[ ]Part-time
C. DATES OF EMPLOYMENT
From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __
Month
Day
Year
Month
D. RECORD APPLICANT'S POSITION TITLE(S)
E. GIVE BRIEF DESCRIPTION OF DUTIES PERFORMED BY THE APPLICANT.
I do hereby declare that this information is true and correct.
Signature
Date
IL486-1348 04/06 (L&T)
Title
Day
Year
IMPORTANT NOTICE: Completion of this form is
necessary for consideration for licensure under 225
ILCS 65/1 et.seq. of (Illinois Compiled Statutes).
Disclosure of this information is VOLUNTARY.
However, failure to comply may result in this form
not being processed.
SUPPORTING DOCUMENT
TEMPORARY PERMIT
TP-NUR
APPLICANT: This form must be completed in its entirety and accompanied by the four (4) page application jacket.
1.
NAME
LAST
FIRST
MIDDLE
2.
DATE OF BIRTH
3.
SOCIAL SECURITY NUMBER
__ __ / __ __ / __ __ __ __
4.
ADDRESS STREET, CITY, STATE, ZIP CODE
6.
MAIDEN OR GIVEN SURNAME
5.
Month
Day
Year
REFER TO REFERENCE SHEET. Record profession name and three
digit profession code for which you are making Illinois application.
Profession Code
Profession Name
7. Nursing Education Program Completed.
Location of Program
Name of Program
Year of Graduation
8. Licensure examination taken in your state of original licensure which was the basis for your initial licensure:
NAME OF EXAMINATION
DATE OF
EXAMINATION
RESULTS
Passed
Failed
DATE OF
EXAMINATION
RESULTS
Passed
Failed
National Council Licensure Examination
for Registered Nurses (NCLEX-RN)
National Council Licensure Examination
for Practical Nurses (NCLEX-PN)
Other:
9. List all states where you hold active current licenses for the profession for which you are now making application:
10. Which one of the states noted above is the state where you have most recently been practicing?
11. Have you been convicted of any crime under the laws of any jurisdiction of the United States: (a) which is a felony; or
(b) which is a misdemeanor directly related to the practice of the profession within the last five (5) years?
Yes No
If so, submit certified copies of all court records pertaining to said conviction.
12. Have you had a license or permit related to the practice of nursing revoked, suspended, or placed on probation by another
jurisdiction within the last five (5) years?
Yes
No
If so, have appropriate board of nursing complete CT-NUR form and attach copies of disciplinary action.
I certify the information and documents contained in this application are true and correct to the best of my knowledge. I
understand should any of the information or documents contained herein be proven false, it may result in the denial of my
Temporary Permit request and/or permanent endorsement/restoration application or other appropriate disciplinary action.
Signature
IL486-1577 12/00 (NS)
Date
IMPORTANT NOTICE
CRIMINAL BACKGROUND CHECK INFORMATION
Individuals applying for licensure for professions that require fingerprints must submit to a criminal background check and provide evidence of fingerprint processing from a fingerprint vendor licensed by the
Department. Fingerprints must be taken within 60 days from the date that the application is submitted to
the Department or the Department’s testing vendor.
Applicants may contact a licensed fingerprint vendor to schedule an appointment for fingerprinting
by going to https://www.idfpr.com/FPVendor.asp. The Illinois State Police will transmit electronic
results of fingerprint processing to the Department. A receipt issued by a licensed fingerprint vendor agency must be submitted with the application fee. The receipt shall be issued by the fingerprint
vendor at the time the fingerprints are obtained.
Out-of-State applicants who are unable to schedule an appointment for fingerprinting through a
licensed fingerprint vendor need to complete the following steps:
Obtain one (1) Illinois State Police (ISP) Fee Applicant Card for processing. Applicants may
contact the Department at 1-800-560-6420 or send an email request on your profession
page of the Department website at www.idfpr.com. The ISP will transmit electronic results
of the fingerprint processing to the Department.
Complete Section 1 of the Identity Verification Certifying Statement form.
The Fee Applicant Card shall be taken to a police department in another state to obtain
classifiable prints.
Section 2 of the Identity Verification Certifying Statement shall be completed and signed
by the police department.
Go to www.idfpr.com to select a licensed fingerprint vendor that has “Card Scan” capability.
Contact the vendor to determine the fee for a “Card Scan”.
Mail the original Identity Verification Certifying Statement (with Sections 1 and 2 completed),
Fee Applicant card and fingerprint fee to the licensed fingerprint vendor selected from the
Division of Professional Regulation website.
Mail the completed application, licensing fee and a copy of the Identity Verification Certifying
Statement (with Sections 1 and 2 completed) to the Division of Professional Regulation.
PRIVACY STATEMENT
I, the undersigned, hereby authorize the release of any criminal history record information that may exist
regarding me from any agency, organization, institution, or entity having such information on file. I am aware
and understand that my fingerprints may be retained and will be used to check the criminal history record
information files of the Illinois State Police and/or the Federal Bureau of Investigation. I also understand that if
my photo was taken, my photo may be shared only for employment or licensing purposes. I further understand
that I have the right to challenge any information disseminated from these criminal justice agencies regarding
me that may be inaccurate or incomplete pursuant to Title 28 Code of Federal Regulation 16.34 and Chapter 20
ILCS 2630/7 of the Criminal Identification Act.
IL486-2052 NEW
4/15
IMPORTANT NOTICE: Completion of
this form is necessary for licensure/
employment under provision set forth
within the Illinois Compiled Statutes or
other related Federal laws. Disclosure
of this information is VOLUNTARY.
However, failure to comply may result
in the denial of your application.
IDENTITY VERIFICATION CERTIFYING
STATEMENT
OOS-FP
Pursuant to Title 68 Part 1240.535 of the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and
Locksmith Act of 2004 Rules, fingerprint vendors are required to confirm identity of the individual seeking to be fingerprinted. This identity verification form must be completed for out-of-state residents applying for licensure/employment in
the State of Illinois. This form will be utilized to confirm the personal identifying information being placed on the Illinois
State Police (ISP) Fee Applicant fingerprint card, form number ISP-404. The out-of-state agency chosen to take your
fingerprints, must complete this form, as written confirmation that a valid government issued drivers license or State ID
was presented and that the identification provided, belongs to the individual being fingerprinted.
Instructions: This form must be submitted, along with a manual Fee Applicant fingerprint card to which your fingerprints have been applied, to a licensed live scan fingerprint vendor in the State of Illinois possessing “Scan Card” capability to ensure electronic transmission of the Fee Applicant fingerprint card. The electronic transmission of fingerprints
to the ISP is mandated pursuant to Title 20 Part 1265 “Electronic Transmission of Fingerprints”. The manual submission of fingerprints to ISP is no longer acceptable. Once your fingerprints have been taken, a signed original of this
form must be attached to your Fee Applicant fingerprint card and submitted to an Illinois licensed live scan fingerprint
vendor. As well, an additional copy may be required to be submitted to the requesting State Agency along with any additional application or required documentation specified by the State Agency.
Section 1 Applicant Information (All fields mandatory)
LAST NAME:
FIRST:
PHONE NUMBER:
MIDDLE:
POSITION / REASON FINGERPRINTED: (NURSE/DOCTOR/SECURITY GUARD, ETC)
MAIDEN NAME/GIVEN SURNAME:
ADDRESS: (STREET/CITY/STATE/ZIP)
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
Section 2 Certifying Agency Taking Fingerprints (Include TCN from Fee Applicant card)
AGENCY NAME:
TCN: FRM
DATE FINGERPRINT TAKEN:
PRINTING AGENT’S NAME:
/
/
LAST
CONTACT PHONE NUMBER:
(
)
-
FIRST
I have compared the government issued identification presented by the applicant and attest that to the
best determination, I have fingerprinted the same individual. (Must be checked to certify)
PRINTING AGENT’S SIGNATURE:
Illinois Live Scan Fingerprint Vendor Information
Section 3 Fingerprint Vendor Agency Name
LIVE SCAN FP AGENCY NAME:
REQUESTING STATE AGENCY:
REQUESTING STATE AGENCY ORI:
DATE FINGERPRINTS SUBMITTED TO ISP:
COST CENTER USED:
IL486-2222
4/15
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