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 Carefully follow all steps outlined on the INSTRUCTION SHEET. In
Licensure and/or Examination in Illinois: addition, note the following:
1.Four page APPLICATION FOR LICENSURE AND/OR A. Type or print legibly with black ink only.
EXAMINATION. B. FEES ARE NOT REFUNDABLE.
2. INSTRUCTION SHEET, which gives step by step ap- C. Disclosure of your U.S. social security number, if you have one, is
plication instructions for your profession. mandatory, in accordance with 5 Illinois Compiled Statutes 100/10-65
3. REFERENCE SHEET, which gives detailed coding to obtain a license. The social security number may be provided to
information for your profession. the Illinois Department of Public Aid to identify persons who are more
4. SUPPORTING DOCUMENTS, forms, and/or any other than 30 days delinquent in complying with a child support order, or
documentation you may be required to submit with to the Illinois Department of Revenue to identify persons who have
your application. failed to file a tax return, pay tax, penalty or interest shown in a filed
5. If the name shown on your supporting documents is differ- return, or to pay any final assessment or tax penalty or interest, as
ent from that shown on your application, you must submit required by any tax Act administered by the Illinois Department of
PROOF OF LEGAL NAME change - copy of marriage Revenue, or to other entities for verification of identification.
license, divorce decree, affidavit or court order.
PART I: Application Category Information
A. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4
1. PROFESSION NAME 2. PROFESSION CODE 3. LICENSURE METHOD 4. FEE
$
B. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION
This is the first time I have made application for this My application for this profession had previously been denied
profession in Illinois. in Illinois. I am reapplying since I have fulfilled additional
I have previously made application for this profession in requirements.
Illinois. However, my previous application expired and I I have previously made application for this profession in
am now reapplying. Illinois. However, I am now applying under new statutory
Other: language.

PART II: 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.
1. NAME LAST FIRST MIDDLE 2. TITLE (e.g., M.D., D.D.S., etc.) 3. UNITED STATES SOCIAL SECURITY NO.

4. PERMANENT MAILING ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY

5. BUSINESS ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY

6. MAIDEN, GIVEN SURNAME, OR ANY NAME(S) UNDER WHICH SUPPORTING 7. MOTHER'S MAIDEN NAME
DOCUMENTS WILL BE SUBMITTED. (SEE INSTRUCTIONS #5 ABOVE)

8. PLACE OF BIRTH CITY STATE/COUNTRY 9. DATE OF BIRTH 10. AGE

Female
Month Day Year Male
11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED 12. REQUIRED
Work: ( __ __ __ ) __ __ __ __ __ __ __ __ Home: ( __ __ __ ) __ __ __ __ __ __ __ __ E-MAIL ADDRESS
(Area Code) (Area Code)
__
Fax: ( __ __ __ ) __ __ __ __ __ __ __ Fax: ( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code) (Area Code)
IL486-1019 07/16 (LT) 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.
 NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________
PART III: Education Information

1. PRELIMINARY EDUCATION (Elementary and High School or G.E.D. Circle number of years completed)
Graduated Received
1 2 3 4 5 6 7 8 9 10 11 12
High School? Yes No OR G.E.D.? Yes No
2. NAME OF LAST PRELIMINARY SCHOOL 3. LAST PRELIMINARY SCHOOL LOCATION 4. DATE OF GRADUATION
ATTENDED (City and State)
Month Year
5. COLLEGE OR UNIVERSITY (Circle number of years completed)
1 2 3 4 5 6 7 8 Graduated? Yes No

6. COLLEGE OR UNIVERSITY NAME LOCATION DATES OF ATTENDANCE TYPE OF

(Undergraduate and Graduate) (City and State or Country) FROM TO DEGREE EARNED

Month/Year Month/Year

7. SPECIALIZED TRAINING (Residency, Professional Training, Vocational Training, Practical or Clinical Training)
LOCATION DATES OF ATTENDANCE Did You Complete
INSTITUTION NAME (City and State or Country) FROM TO Training?
Month/Year Month/Year
Yes No

Yes No

Yes No

Yes No

Yes No

IL486-1019 APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 2 of 4

 NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________
PART IV: Record of Licensure 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 Licen-
sure 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.

DATE OF LICENSE STATUS

STATE PROFESSION NAME LICENSE NUMBER ISSUANCE (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 VI: Personal History Information (This part must be completed by all applicants) 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 personal
statement describing the circumstances of the conviction and certified copies of court records of your conviction including the nature of
the offense, date of discharge, and a statement from the probation or parole office. In general, a criminal conviction by itself does not
usually result in denial of licensure.

2. Have you been convicted of a felony? In general, a felony conviction by itself does not usually result in denial of licensure.

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. Do you 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? Yes No
(NOTE: If you are not subject to a child support order, answer "no.")

2. 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? Yes No

PART IX: 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
 IMPORTANT NOTICE: Completion of SUPPORTING DOCUMENT
this form is necessary to accomplish the
requirements outlined in 225 of the Illinois
HEALTH CARE WORKERS
Compiled Statutes. Disclosure of this
information is VOLUNTARY. However,
failure to comply may result in this form not
CHARGED WITH OR CONVICTED
OF CRIMINAL ACTS
CCA
being processed.

1. NAME LAST FIRST MIDDLE 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 Naprapaths Physician Assistants

Advanced Practice Nurses Nursing Home Administrators Podiatrists
Athletic Trainers Occupational Therapists Professional Counselors
Audiologists Occupational Therapy Assistants Prosthetists
Clinical Psychologists Optometrists Registered Nurses
Clinical Social Workers Orthotists Registered Surgical Assistants
Dental Hygienists Pedorthists Registered Surgical Technologists
Dentists Perfusionists Respiratory Care Practitioners
Genetic Counselors Pharmacists Speech Pathologists
Licensed Clinical Professional Physical Therapists
Counselors Physical Therapy Assistants
Licensed Practical Nurses Physicians, including Medical Doctors (M.D.), Doctors
Licensed Social Workers of Osteopathic Medicine (D.O.), and Chiropractic
Marriage and Family Therapists 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:

1) Are you currently charged with or have you been convicted of a criminal act that requires registration Yes No
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? *

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 Date

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