PACKET UPDATED 8/1/24DPR-SW 8/24
The requirements of licensure and practice for Illinois Licensed Social Worker (LSW) and Illinois Licensed
Clinical Social Worker (LCSW) licensure are provided by the ACT (225 ILCS 20/) and the RULES in
Administrative Code (68 IAC Part 1470).
The ACT and RULES are available online at: www.idfpr.illinois.gov/profs/SocialWorker.html
STEP 1.
Determine the level of license desired. There are two tiers of Illinois Social Worker licensure:
Licensed Social Worker (LSW) – Licensed Social Workers must operate at all times under the order,
control, and full professional responsibility of a qualifi ed supervisor. The type of license required for a
qualifi ed supervisor depends on the type experience being supervised. Profession Code 150.
Licensed Clinical Social Worker (LCSW) – This is the independent practice level license. Profession
Code 149.
For more information on roles and responsibilities or scope of practice of each profession, please refer to
Sections 3 (Defi nitions), 4 (Exemptions), 9 (Qualifi cations), and 10 (License Restrictions and Limitations)
of the ACT.
INSTRUCTIONS
Non-Examination (LSW ONLY)
Endorsement
Acceptance of Examination (LCSW ONLY)
Examination (LCSW ONLY)
Licensed Social Worker
or
Licensed Clinical Social Worker
EXAMINATION (or Pre-Examination Approval) - LCSW ONLY. The applicant in this situation is not
actively licensed and has not successfully completed the required licensure examination. An applicant in
this situation is seeking approval from the Illinois Department of Financial and Professional Regulation
(Department) and/or the Illinois Social Work Examining and Disciplinary Board (Board) to register and
sit for the exam. Licensure Application Fee is $50.
An individual planning to obtain LCSW licensure by LCSW Exam Alternative should apply under
the EXAMINATION method.
For more information about the required licensure examination, please refer to Section 1470.70 of the
RULES.
RESTORATION - The applicant in this situation already holds an Illinois license as an LSW or LCSW
but the license has been inactive or not renewed for fi ve (5) years or more. An application to restore will
be reviewed according to the requirements of Rules 68 IAC Section 1470.80 (c). Candidates seeking to
reactivate a license that is not-renewed or inactive may contact the DPR Call Center at 800/560-6420 to
request instructions, forms and fees.
SOCIAL WORKER - PAGE 2
STEP 2.
There are four (4) pathways (or LICENSURE METHODS) to Illinois social worker licensure. Use the
descriptions below to determine which LICENSURE METHOD best fi ts your situation. You may apply
under only one.
NON-EXAMINATION – LSW ONLY. An LSW seeking licensure under Illinois Public Act 102-0326 is
not required to complete an examination. This licensure method does not apply to LCSW licensure.
Licensure Application Fee $50.
ENDORSEMENT - The applicant in this situation is actively licensed as an LSW or LCSW (or
equivalent license) in another state or US jurisdiction. This candidate has successfully completed
the required licensure examination or may be required to complete it as part of the licensure process.
License Application Fee $200
ACCEPTANCE OF EXAMINATION - LCSW ONLY. The applicant in this situation is not actively
licensed but has already successfully completed the required licensure examination. Licensure
Application Fee is $50.
SOCIAL WORKER - PAGE 3
1. Profession Name 2. Profession Code 3. Licensure Method 4.Fee
Enter the license desired
(from STEP 1).
Enter the corresponding
profession code for the
license selected in STEP 1.
Select only one licensure
method (from STEP 2)
that fi ts your situation and
enter it.
Enter the corresponding
fee for the licensure
method selected in
STEP 2.
STEP 3.
Use the information from STEP 1 and STEP 2 and the chart below to complete PART I (Page 1), Box A.,
Items 1-4 of the application.
STEP 4.
Complete the rest of the 4-page application, noting the following:
PART IV: Record of Licensure Information (Page 3)
Applicants who have never held a social work license may mark N/A for “not available” or “not
applicable” in of the application.
PART V: Record of Examination (Page 3)
All attempts (pass or fail) of Association of Social Work Boards (ASWB) examinations must be listed.
List the level of the exam (ASSOCIATE, BACHELORS, MASTERS, ADVANCED GENERALIST, or
CLINICAL). Applicants should also list other state licensing or jurisprudence exams if diff erent than
ASWB exams. Candidates who have never taken a licensure examination may mark N/A for “not avail-
able” or “not applicable” in of the application.
PART VII: EXAMINATION CODING INFORMATION
This portion of the application is not used for LSW or LCSW applications. Please leave this part of the
application blank or mark N/A for “not applicable”. A separate examination registration process is fol-
lowed when an LCSW applicant has been approved to take the exam.
SOCIAL WORKER - PAGE 4
STEP 5.
SUPPORTING DOCUMENTS - The following supporting documents may be required with your
application. Read the instructions for each form thoughtfully.
Licensure Application Fee- The license application fee can be paid with a US check or money
order made payable to IDFPR, or online using the ePay Portal at:
https://idfpr.illinois.gov/epay.html. DO NOT SEND CASH. Pay only one fee for
only one licensure method.
PHQ form - This form is required to be completed by all applicants.
ED form(s) - This form is required for all licensure methods. The applicant
completes the “APPLICANT” portion of the form, then arranges for his or her social
work program college or university to complete the “SCHOOL OFFICIAL” portion of the
form. The school offi cial’s original signature and seal is required, do not submit
photocopies. Do not submit the form unless it has been completed by the social
work program. A separate form is required for each college or university through
which social work coursework was completed. Education requirements are detailed
in RULES Section 1470.30. Candidates with Social Work degrees completed outside of the
United States may arrange for their degree to be evaluated by the Council on Social
Work Education’s (CSWE) International Social Work Degree Recognition and Evaluation
Service.
CT form - A candidate who is licensed as a Social Worker in another state or U.S. Jurisdiction must
provide Certifi cation of Licensure from his or her fi rst state of social work licensure and
the state she or he has most recently been practicing. The applicant must contact the
appropriate Board or Agency in the other state(s) to arrange for an original Certifi cation of
Licensure to be sent directly to the Department. IDFPR will accept other states' formats for
Certifi cation of Licensure in lieu of the CT form as long as the information provided by the
other state includes the same basic required information.
Offi cial Score Report – A candidate applying under the ENDORSEMENT or ACCEPTANCE OF
EXAMINATION licensure methods must contact the Association of Social Worker
Boards (ASWB) to arrange for an offi cial, original examination for score report to be sent
directly to the Department.
VE-SW – This form must be completed for all LCSW applications or for any LSW applicant
applying on the basis of a bachelor’s degree and three (3) years’ experience. The applicant
completes the “APPLICANT” portion of the form, then arranges for the supervisor to
complete the “SUPERVISOR” portion of the form. The Supervisor’s original signature is
required - photocopies are not acceptable. Supervised experience requirements are detailed
in RULES Section 1470.20. An individual applying under the ENDORSEMENT licensure
method who has been licensed at the independent level in another state or U.S.
jurisdiction for 5 consecutive years without discipline may submit Certifi cation of
Licensure (CT forms) for each state in which the applicant practiced in the last 5
years instead of submitting the following documents: ED form, VE-SW form, Offi cial
Score Report.
SOCIAL WORKER - PAGE 5
Personal History Documents - An applicant marking “YES” in response to any of the personal history
questions in PART VI, page 4 of the application will need to provide a signed, dated
personal statement personal statement of explanation and corresponding documentation. For
criminal issues please provide a certifi ed copy of the disposition from the court or a
statement from the court why one is not available. For medical disclosures please provide a
physician’s statement that includes whether or not the condition being disclosed will
prevent you from performing the essential functions of a social worker.
Proof of name change(s) - If any of the supporting documents listed above list a diff erent name than the
name on the application, proof of name change(s) must be submitted. An applicant must
document each step of each change. Examples of acceptable documentation include: Signed
Marriage Certifi cates, Marriage Licenses, Divorce Decrees, Court orders showing change(s)
of name.
STEP 6.
The application, supporting documents, and application fee may be submitted with the application or to:
Illinois Department of Financial and Professional Regulation
Division of Professional Regulation
P.O. Box 7007
Springfi eld, Illinois 62791
To pay online please visit: https://idfpr.illinois.gov/epay.html.
An application is valid for 3 years from date it is received by the Department.
Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov.
For assistance--Call one of the following numbers and state that you are applying to become licensed as a
social worker and need help with your application:
1-800-560-6420
TTY - 1-866-325-4949
Please allow 6 weeks from mailing your application before making an inquiry concerning its status.
IMPORTANT NOTICE
Elder and Child Abuse Reporting
"Pursuant to Public Act 91-0244, eff ective 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 fi nancial 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
This Page Left Blank
This is the fi rst time I have made application for this
profession in Illinois.
I have previously made application for this profession in
Illinois. However, my previous application expired and I
am now reapplying.
Other:
4. PERMANENT MAILING ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY
5. BUSINESS ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY
PART I: Application Category Information
4. FEE
C. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION
3. SSN OR ITIN
6. MAIDEN, GIVEN SURNAME, OR ANY NAME(S) UNDER WHICH SUPPORTING DOCUMENTS WILL BE SUBMITTED.
(SEE INSTRUCTIONS #5 ABOVE)
The following materials are required to make Application for Licensure and/
or Examination in Illinois:
1. 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 diff erent from
that shown on your application, you must submit PROOF OF LEGAL
NAME change - copy of marriage license, divorce decree, affi davit or
court order.
1. PROFESSION NAME
1. NAME LAST FIRST MIDDLE
7. PLACE OF BIRTH CITY STATE/COUNTRY
10. TELEPHONE NUMBER WHERE YOU MAY BE REACHED
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
fi le this application in order to receive any further information.
IL486-1019E 7/24
3. LICENSURE METHOD
2. PROFESSION CODE
My application for this profession had previously been denied
in Illinois. I am reapplying since I have fulfi lled additional
requirements.
I have previously made application for this profession in
Illinois. However, I am now applying under new statutory
language.
2. TITLE (e.g., M.D., D.D.S., etc.)
Day Year
8. DATE OF BIRTH
Month
$
B. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4
Carefully follow all steps outlined on the INSTRUCTION SHEET. In addition,
note the following:
A. Type or print legibly with black ink only.
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 fi le a tax return, pay tax, penalty or
interest shown in a fi led return, or to pay any fi nal assessment or tax penalty
or interest, as required by any tax Act administered by the Illinois Department
of Revenue, or to other entities for verifi cation of identifi cation.
9. AGE
Female
Male
Work: ( __ __ __ ) __ __ __
__
__ __ __ __ Home: ( __ __ __ ) __ __ __
__
__ __ __ __
(Area Code) (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.illinois.gov
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.
A. Check the box indicating the appropriate information regarding your application. Military Military Spouse Not Military Decline to Answer
Military service member is defi ned as. “Service member means any person who, at the time of application under this Section, is an active duty member of the United
States Armed Forces or any reserve component of the United States Armed Forces, the Coast Guard, or the National Guard of any state, commonwealth, or territory
of the United States or the District of Columbia or whose active duty service concluded within the preceding 2 years before application.” The following will be
considered proof of you or your spouse’s active military status: DD214, Letter of Service signed by Unit Commanding Offi cer, or Proof of Service document from the
Servicemember's electronic personnel portal. Proof for Spouses: Military Permanent Change of Station Orders with the spouse identifi ed by name; Offi cial
Notifi cation of Change of Assignment with your marriage license, a certifi ed DD1172 verifying marital status, or a letter signed by the commanding offi cer verifying
change of assignment and the name of the military spouse.
11. EMAIL ADDRESS (REQUIRED)
12. I CONSENT TO PROFESSIONAL
ORGANIZATIONS HAVING
MY EMAIL ADDRESS
Graduated Received
High School? Yes No OR G.E.D.? Yes No
1 2 3 4 5 6 7 8 9 10 11 12
Graduated? Yes No
LOCATION
(City and State or Country)
DATES OF ATTENDANCE
FROM TO
TYPE OF
DEGREE EARNED
6. COLLEGE OR UNIVERSITY NAME
(Undergraduate and Graduate)
Month/Year
DATES OF ATTENDANCE
FROM
TO
LOCATION
(City and State or Country)
Yes No
Yes No
Yes No
Yes No
Yes No
Month/YearMonth/Year
Did You Complete
Training?
Month/Year
Month Year
4. DATE OF GRADUATION
PART III: Education Information
1. PRELIMINARY EDUCATION (Elementary and High School or G.E.D. Circle number of years completed)
INSTITUTION NAME
1 2 3 4 5 6 7 8
2. NAME OF LAST PRELIMINARY SCHOOL
ATTENDED
3. LAST PRELIMINARY SCHOOL LOCATION
(City and State)
5. COLLEGE OR UNIVERSITY (Circle number of years completed)
7. SPECIALIZED TRAINING (Residency, Professional Training, Vocational Training, Practical or Clinical Training)
IL486-1019E
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 2 of 4
NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________
PART IV: Record of Licensure Information
IL486-1019E
(If additional space is needed, attach a separate sheet.)
PROFESSION NAMESTATE
State of Current Licensure where you
most recently have been practicing.
Other States of Licensure
NAME OF EXAMINATION
(If additional space is needed, attach a separate sheet.)
PART V: Record of Examination
DATE OF
ISSUANCE
LICENSE NUMBER
LICENSE STATUS
(Active, Lapsed, etc.)
STATE
MONTH/YEAR EXAM RESULTS
(Passed, Failed, Absent)
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.
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 Certifi cation(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, certifi cation 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 of Original Licensure
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 3 of 4
NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________
1. Have you been convicted of or pled guilty or nolo contendere to any criminal off ense in any state or in federal court? Please do not give
details on minor traffi c 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 certifi ed copies of court records of your conviction including the nature of
the off ense, date of discharge, and a statement from the probation or parole offi ce. 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 Certifi cate of Relief from Disabilities by the Prisoner Review Board? If yes, attach a copy of the certifi cate.
4. Do you now have any disease or condition that presently limits 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? 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 VI: Personal History Information (This part must be completed by all applicants)
NOYES
PART IX: Method of Payment and Certifying Statement
IL486-1019E
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 4 of 4
PART VIII: Child Support, Tax Information and Workers' Compensation (Every applicant is required by law to
respond to the following questions)
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:
NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________
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 ILCS 2105-15(g), "The Department shall deny any license application or renewal authorized under any licensing Act
administered by the Department to any person who has failed to fi le a return, or to pay the tax, penalty, or interest shown in a fi led return, or to
pay any fi nal assessment of tax, penalty, or interest, as required by any tax Act administered by the Illinois Department of Revenue, until such
time as the requirement of any such tax Act is satisfi ed."
Are you delinquent in the fi ling of state taxes? Yes No
3. In accordance with 20 ILCS 2105/2105-15(g-5), “The Department shall refuse the issuance or renewal of a license to, or suspend or revoke
the license of, any individual, corporation, partnership, or other business entity that has been found by the Illinois Workers' Compensation
Commission or the Department of Insurance to have failed to secure workers' compensation obligations, or pay in full a fi ne or penalty imposed
due to a failure to secure workers' compensation obligations.”
Are you delinquent in complying with workers’ compensation obligations? Yes No
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. I UNDERSTAND THAT FEES ARE NOT REFUNDABLE.
Signature of Applicant Date
Check / Money Order. Check Number: _____________
Online. Paid Online at:https://idfpr.illinois.gov/epay.html in the amount of ______________. Approved #:______________
4. Do you certify you have fully complied with this profession’s continuing education requirements? Yes No
NOTE: Continuing education is not required for the fi rst renewal of this license. If this is your fi rst renewal, please answer (Yes) to this question.
Making a false statement may subject the licensee to disciplinary action.
You may verify the continuing education requirements of your profession here: https://idfpr.illinois.gov/rules2015.html
Pursuant to 20 ILCS 2105-165(a), the Department requires the following professionals to disclose information regarding charges or
convictions pertaining to certain off enses. Please check applicable profession.
Advanced Practice Registered Nurse
Acupuncturist
Audiologist
Dental Hygienist
Sex Off ender Evaluator
Dentist
Athletic Trainer
Genetic Counselor
Marriage and Family Therapist
Sex Off ender Associate
Licensed Practical Nurse
Psychologist, Clinical (LCP)
Professional Counselor, Clinical
(LCPC)
Registered Nurse
Sex Off ender Treatment Provider
Respiratory Care Practitioner
Podiatrist
Registered Surgical Assistant
Registered Surgical Technologist
Prosthetist
Advanced Practice Registered
Nurse - Full Practice Authority
Behavior Analyst
Behavior Analyst Assistant
Certifi ed Midwife
Chiropractic Physicians (D.C.)
Professional Counselor (LPC)
Physician Assistant
Occupational Therapist
Occupational Therapy Assistant
Naprapath
Pharmacist
Physical Therapist
Physicians, including Medical
Doctors (M.D.), Doctors of
Osteopathic Medicine (D.O.)
Physical Therapy Assistant
Nursing Home Administrator
Orthotist
Pedorthist
Optometrist
Perfusionist
Social Worker, Clinical (LCSW)
Social Worker (LSW)
Speech Pathologist
IMPORTANT NOTICE: Completion of
this form is necessary to accomplish the
requirements outlined in 20 ILCS 2105 of
the Civil Administrative Code. Disclosure of
this information is REQUIRED.
HEALTH CARE WORKERS
ADDITIONAL PERSONAL HISTORY
QUESTIONS
SUPPORTING DOCUMENT
PHQ
1. NAME LAST FIRST MIDDLE
2. ADDRESS STREET, CITY, STATE, ZIP CODE
3. PROFESSIONAL LICENSE NUMBER (if any)
__ __ __ - __ __ __ __ __ __
4. SOCIAL SECURITY NUMBER OR ITIN
__ __ __ - __ __ - __ __ __ __
Certifi cation 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.
In order for your application to be evaluated, you must respond to each of the following questions:
IL486-2034 12/23
Signature of Applicant Email Date
Page 1of 3
If YES to any of the above, attach a personal statement describing the circumstances of the charge or conviction and
a certifi ed copy of the court records regarding your charge or conviction, including the nature of the off ense and date of
discharge, if applicable, as well as a statement from the probation or parole offi ce.
Are you required, as part of a criminal sentence, to register under the Sex Off ender Registration Act? *
3)
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 off ense based on sexual conduct or sexual penetration?
2)
Yes
No
Are you currently charged with or have you been convicted of a criminal act that requires registration
under the Sex Off ender Registration Act? *
1)
Are you currently charged with or have you been convicted of a forcible felony? *
4)
Marriage and Family Therapist Assoc.
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.
Music Therapist
IL486-2034 02/13 (crimacts)
Page 2 of 3
* DEFINITIONS
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).
10-1 (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 off ense, provided the off ense was sexually motivated as
defi ned in Section 10 of the Sex Off ender 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 off ense
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 off ense was committed on or after January 1, 1998,
provided the off ense was sexually motivated as defi ned in Section 10 of the Sex Off ender Management Board Act.
(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 off ense was sexually motivated as defi ned in Section 10 of the Sex Off ender Management
Board Act, and the off ense was committed on or after January 1, 1996:
(1.10) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the off ense was committed on
or after July 1, 1999:
10-4 (forcible detention, if the victim is under 18 years of age), provided the off ense was sexually motivated as defi ned
in Section 10 of the Sex Off ender 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 off ense 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 off ense was
committed on or after August 22, 2002.
(2) A violation of any former law of this State substantially equivalent to any off ense listed in subsection (B) of this Section.
(C) A conviction for an off ense of federal law, Uniform Code of Military Justice, or the law of another state or a foreign country that is
substantially equivalent to any off ense listed in subsections (B), (C), (E), and (E5) of this Section shall constitute a conviction for the
purpose of this Article.
10-2 (aggravated kidnapping),
An attempt to commit any of these off enses.
730 ILCS 150 et. seq:—Acts that require Sex Off ender Registration:
(B) As used in this Article, “sex off ense” means:
(1) A violation of any of the following Sections of the Criminal Code of 1961:
* 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 off enses:
a) First Degree Murder (Section 9-1);
b) Intentional Homicide of an Unborn Child (Section 9-1.2);
c) Second Degree Murder (Section 9-2);
d) Voluntary Manslaughter of an Unborn Child (Section 9-2.1);
e) Drug-induced Homicide (Section 9-3.3);
f) Kidnapping (Section 10-1);
g) Aggravated Kidnapping (Section 10-2);
h) Unlawful Restraint (Section 10-3);
i) Aggravated Unlawful Restraint (Section 10-3.1);
j) Forcible Detention (Section 10-4);
k) Involuntary Servitude (Section 10-9(b));
l) Involuntary Sexual Servitude of a Minor (Section 10-9(c));
m) Traffi cking in Persons (Section 10-9(d));
n) Criminal Sexual Assault (Section 11-1.20);
o) Aggravated Criminal Sexual Assault (Section 11-1.30);
p) Predatory Criminal Sexual Assault of a Child (Section 11-1.40);
q) Criminal Sexual Abuse (Section 11-1.50);
r) Aggravated Criminal Sexual Abuse (Section 11-1.60);
s) Aggravated Battery (Section 12-3.05);
t) Compelling Organization Membership of Persons (Section 12-6.5);
u) Compelling Confession or Information by Force or Threat (Section 12-7);
v) Home Invasion (Section 12-11);
w) Robbery (Section 18-1);
x) Armed Robbery (Section 18-2);
y) Vehicular Hijacking (Section 18-3);
z) Aggravated Vehicular Hijacking (Section 18-4);
bb) Terrorism (Section 29D-14.9);
cc) Causing a Catastrophe (Section 29D-15.1);
dd) Possession of a Deadly Substance (Section 29D-15.2);
ee) Making a Terrorist Threat (Section 29D-20);
ff ) Falsely Making a Terrorist Threat (Section 29D-25);
gg) Material Support for Terrorism (Section 29D-29.9);
hh) Hindering Prosecution of Terrorism (Section 29D-35);
ii) Boarding or Attempting to Board an Aircraft with Weapon (Section 29D-35.1);
jj) Armed Violence (Section 33A-2); and
kk) Attempt (Section 8-4) of any of the above specifi ed off enses.
IL486-2034 02/13 (crimacts)
Page 3 of 3
aa) Aggravated Robbery (Section 18-5);
This Page Left Blank
RETURN COMPLETED FORM TO APPLICANT
LICENSING AGENCY: The Illinois Department of Financial and Professional Regulation will accept other forms
of certifi cation provided all applicable information requested on this form is contained in
the certifi cation. Please record N/A in areas which are not applicable.
PART I - CERTIFICATION OF EXAMINATION STATUS
A. The applicant has written is scheduled to write the following examination:
Date of ExaminationName of Examination
B. The applicant has or will have written the above-named examination _______ number of times.
PART II - CERTIFICATION OF LICENSURE
C. ISSUANCE DATE OF LICENSE
A. NAME OF PROFESSION AS IT APPEARS ON LICENSE
D. EXPIRATION DATE OF LICENSE
B. LICENSE NUMBER
E. LICENSURE METHOD
Examination (Administered in Your State)
National (Name) _____________________
State Constructed _____________________
Other (Name) _____________________
Endorsement of License (State) _____________________
Acceptance of Examination Results _____________________
(Administered in Another State)
F. CURRENT LICENSURE STATUS G. IF LICENSED BY EXAMINATION, RECORD SCORES
Active
Inactive
Lapsed
Other (Explain) ______________________________
___________________________________________
___________________________________________
Type of Examination Score
Written ________
Practical ________
Other (Describe) ____________________
___________________________________
Received no Grade Below ________
Examination Period _____ days ______ hours
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.
SUPPORTING DOCUMENT
CERTIFICATION BY LICENSING
AGENCY / BOARD
CT
APPLICANT: Complete the applicant section of this form then forward this form to the jurisdiction in which
you are requesting certifi cation by a licensing agency/board. Contact certifying jurisdiction for
appropriate fee. You are authorized to photocopy this form as necessary.
3. SSN OR ITIN
Profession Name Profession Code
4. ADDRESS STREET, CITY, STATE, ZIP CODE 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 7. APPLICANT TELEPHONE NUMBER (Daytime)
2. DATE OF BIRTH
1. NAME LAST FIRST MIDDLE
__ __ __ - __ __ - __ __ __ __
8a. RECORD PROFESSION NAME AS IT APPEARS ON YOUR LICENSE
FROM THE JURISDICTION TO WHICH THIS FORM IS BEING FOR-
WARDED. (If applicable)
8b. LICENSE NUMBER (If appli-
cable)
8c. ISSUANCE DATE OF LICENSE
(If applicable)
I hereby authorize _________________________________________________ to furnish to the Illinois Department of
Financial and Professional Regulation or its designated testing service, the information requested below.
Signature _________________________________________ Date ______________________________________
Name of Licensing Agency or Board
Area Code ( ___ ___ ___ ) ___ ___ ___
__
___ ___ ___ ___
Reciprocity with (State) ________________
Waiver/Grandfather
Credentials
Other (Describe) ____________________
____________________________________
____________________________________
IL486-0850 12/23 (LT)
CT - Certifi cation by Licensing Agency/Board - Page 1 of 2
Month Day Year
__ __ / __ __ / __ __ __ __
A1. National or other Profession Specifi c Examination Date of Examination ___________________
(Record all available information)
Scaled Score __________________ Raw Score ___________________
Standard Deviation __________________ Corrected Score ___________________
National Mean __________________ Percent Score ___________________
PART III - CERTIFICATION OF EXAMINATION SCORES
SCORE
SCORE
SCORE
SCORESUBJECT DATE
SUBJECT DATE
SUBJECT DATE
DATESUBJECT
PART IV - FORMAL ACTIONS
A 2.
B. State Constructed Examination
I certify that the information contained herein is true and correct according to the offi cial records of the State.
IL486-0850 (LT)
Print Name
City, State, ZIP Code
Title
Area Code ( )
Signature
Agency/Board Street Address
Date
Telephone Number
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 fi ne, reprimand, probation, censure, revocation, suspension,
surrender, restriction or limitation? (If yes, attach a certifi ed copy of disciplinary action.) Yes No
PART V - RECIPROCAL REGISTRATION
This state does does not grant the same privilege of reciprocal registration to Illinois registrants.
S E A L
CT - Certifi cation by Licensing Agency/Board - Page 2 of 2
Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT.
Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.
NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________
Total academic years attended _____ _____ _____
OR
Total calendar years attended _____ _____ _____
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.
SUPPORTING DOCUMENT
ED
APPLICANT: Complete the applicant section of this form, then forward it to the school for completion of the remainder
of the form.
1. NAME LAST FIRST MIDDLE
__ __ / __ __ / __ __ __ __
Month Day Year
__ __ __ - __ __ - __ __ __ __
2. DATE OF BIRTH
4. ADDRESS STREET, CITY, STATE, ZIP CODE 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
7. NAME OF INSTITUTION ATTENDED
Profession Name
Profession Code
8. DATE OF GRADUATION / COMPLETION
___ ___ / ___ ___ / ___ ___ ___ ___
Month Day Year
I hereby authorize a school offi cial 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.
SCHOOL OFFICIAL: Complete the bottom portion of this page and the reverse side. RETURN THE COMPLETED
FORM TO THE APPLICANT.
A. NAME OF INSTITUTION
B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE
D. SPECIFIC PROGRAM OR CURRICULUM CONCENTRATION OF
APPLICANT
C. DEPARTMENT OF INSTITUTION
F. APPLICANT WAS (CHECK ONE):
E. MAJOR AREA OF STUDY OF THE APPLICANT
H. DATES OF ATTENDANCE
G. CREDIT HOURS EARNED
(CHECK ONE AND
COMPLETE)
IL486-1306 12/23 (LT)
I.
K. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS WERE MET
M. CHECK THE APPROPRIATE STATEMENT(S) AND COMPLETE
L. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED
J. TYPE OF DEGREE OR CERTIFICATE AWARDED
(e.g., B.A., M.A., M.D., Ph.D.)
N. IF EDUCATION PROGRAM WAS COMPLETED IN LESS THAN THE NORMALLY REQUIRED TIME, PLEASE EXPLAIN:
From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
Full-time Part-time Co-op
_________ Semester Hours
_________ Quarter Hours
_________ Course Hours
CERTIFICATION OF EDUCATION
3. SSN OR ITIN
Date Signature of Applicant
Month Day Year
__ __ /__ __ /__ __ __ __
Applicant has completed program on __ __ / __ __ / __ __ __ __
Applicant will complete program on __ __ / __ __ / __ __ __ __
Applicant has graduated on __ __ /__ __ /__ __ __ __
Applicant will graduate on __ __ /__ __ /__ __ __ __
Month Day Year
ED - Certifi cation of Education - Page 1 of 2
Month Day Year
Month Day Year
Month Day Year
Month Day Year
Month Day Year Month Day Year
Years Months Days
Years Months Days
I certify that the information recorded herein is true and correct according to the offi cial records of this institution.
Title Date
Print Name of School Offi cial Signature of School Offi cial
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
SCHOOL OFFICIAL: RETURN THIS FORM TO APPLICANT
IL486-1306 (LT)
O. USE THIS SPACE TO RECORD ANY OTHER INFORMATION THAT YOU FEEL WOULD ASSIST THE DEPARTMENT IN EVALUATING
THE APPLICANT'S EDUCATIONAL EXPERIENCES.
ATTENTION APPLICANT: FOR INCLUSION WITH THE APPLICATION PACKET.
ED - Certifi cation of Education - Page 2 of 2
SCHOOL SEAL OR NOTARY SEAL
NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________
APPLICANT: Complete the applicant section of this form, then forward it to your supervisor(s). A separate form
is required from each supervisor for each experience.
SOCIAL WORK
VERIFICATION OF
SUPERVISION & EXPERIENCE
8. BUSINESS / INSTITUTION / SITE OF EXPERIENCE HOURS
7. CLINICAL SUPERVISOR'S NAME & TITLE
COMPLETE BOXES 7, 8, 9, 10 AND 11 TO REFLECT INFORMATION AT TIME OF EMPLOYMENT/EXPERIENCE
1. NAME LAST FIRST MIDDLE
4. ADDRESS STREET, CITY, STATE, ZIP CODE
11. TYPE OF EXPERIENCE BEING REPORTED (MARK ONLY ONE-
A SEPARATE FORM IS REQUIRED FOR EACH EXPERIENCE).
9. BUSINESS / INSTITUTION / SITE ADDRESS
5. PROFESSION (Check One)
2. DATE OF BIRTH 3. SSN OR ITIN
Area Code ( )
J. APPLICANT'S JOB TITLE AT TIME EXPERIENCE
C. LICENSE STATE D. LICENSE NUMBER E. DATE AWARDED
B. QUALIFICATION TO SUPERVISE:
A. NAME OF SUPERVISOR COMPLETING THIS FORM
F. BUSINESS TELEPHONE NUMBER
PART I. - SOCIAL WORK SUPERVISION INFORMATION
SUPERVISOR: Complete the remainder of this form. RETURN THE COMPLETED FORM DIRECTLY TO THE
APPLICANT IN A SEALED ENVELOPE.
G. EMAIL ADDRESS (OF SUPERVISOR COMPLETING THIS FORM)
L. SUPERVISOR'S BUSINESS/ INSTITUTION/ AGENCY ADDRESS
IL486-0369 6/24 (SW)
6. MAIDEN OR GIVEN SURNAME
SUPPORTING DOCUMENT
VE-SW
VE-SW - Verifi cation of Employment/Experience - Page 1 of 2
Month Day Year
__ __ / __ __ / __ __ __ __
IMPORTANT NOTICE: Completion of this form
is necessary for consideration for licensure
under 225 ILCS 20/1 et. seq. (Illinois Compiled
Statutes). Disclosure of this information is
VOLUNTARY. However, failure to comply may
result in this form not being processed.
Licensed Social Worker (150)
Licensed Clinical Social Worker (149)
10. SUPERVISION WAS (Mark only one):
Internal OR Contracted Outside Supervision
Bachelor's degree + 3 years experience for LSW
Rules 68 IAC Section 1470.20(b)
3000 Supervised Clinical Hours for LCSW
Rules 68 IAC Section 1470.20(a)
Exam Alternative for LCSW
Rules 68 IAC Section 1470.10(a)(2)
Licensed Clinical Social Worker (LCSW)
Licensed Social Worker (LSW) For LSW licensure only
Licensed Clinical Professional Counselor (LCPC)
Licensed Marriage and Family Therapist (LMFT)
Licensed Clinical Psychologist
Licensed Psychiatrist
Licensed Advanced Practice Psychiatric Nurse
Other (specify):
H. The individual listed above and I met for an average
of at least 4 hours each month for the purpose of
conducting supervision. YES NO
If NO, how often was supervision? _____ hours / month.
I. My supervision was coordinated with another clinical
supervisor. YES NO
If YES, the other supervisor's name was:
(A separate VE-SW form is required from each supervisor.)
K. NAME OF SUPERVISOR'S BUSINESS / INSTITUTION / AGENCY
M. Bachelor’s + 3 years experience for LSW. THIS BOX IS ONLY FOR HOURS COMPLETED FOR FIRST TIME
ILLINOIS LSW LICENSURE ON THE BASIS OF A BACHELOR'S DEGREE PURSUANT TO RULES 68 IAC
SECTION 1470.20(b).
The applicant completed the following supervised PROFESSIONAL experience under my supervision. The experience
being counted and reported started as listed below and continued at least until the end date listed below.
_______________(must be after Bachelor’s degree was awarded) _______________ Total: ______________
START DATE (MM/DD/YYYY) END DATE (MM/DD/YYYY) MONTHS and YEARS
The experience was conducted in accordance with Rules 68 IAC Section 1470.20(b). YES NO
N. 3000 Supervised Clinical Hours for LCSW (2000 for Doctorate degree applicants).
THIS BOX IS ONLY FOR HOURS COMPLETED FOR FIRST TIME IL LCSW LICENSURE PURSUANT TO RULES 68 IAC
SECTION 1470.20(a).
The applicant completed the following supervised CLINICAL experience under my supervision. The
experience being counted and reported started as listed below and continued at least until the end date listed
below.
_______________(must be after Master’s or Doctorate degree was awarded) _______________
START DATE (MM/DD/YYYY) END DATE (MM/DD/YYYY)
The experience is ongoing. YES NO Total Number Clinical Hours: _______________
The experience was conducted in accordance with Rules 68 IAC Section 1470.20(a). YES NO
O. Exam Alternative for LCSW. THIS BOX IS ONLY FOR HOURS COMPLETED FOR LCSW EXAM ALTERNATIVE
PURSUANT TO
225 ILCS 20/8.2.
The applicant completed the following supervised PROFESSIONAL experience under my supervision. The
experience being counted and reported started as listed below and continued at least until the end date listed
below.
_______________(must be after Master's or Doctorate degree) _______________ Total hours: ______________
START DATE (MM/DD/YYYY) END DATE (MM/DD/YYYY)
The experience I am verifying was separate from (and in addition to) the 3000 hours (2000 for doctorate degree
applicants) completed or counted for supervised clinical experience per Rules 68 IAC Section 1470.20(a).
YES NO
The experience was conducted in accordance Rules 68 IAC Section 1470.10(a)(2). YES NO
PART I. - SOCIAL WORK SUPERVISION INFORMATION (Continued)
TitleDate
Signature
IL486-0369 (SW)
P. The applicant's performance was satisfactory or better. YES NO
The above indicated experience has been documented by myself and has been performed by the applicant
pursuant to my order, control, and full professional and legal responsibility as a supervisor. I do hereby
declare that the information contained herein is true and correct.
VE-SW - Verifi cation of Employment/Experience - Page 2 of 2
NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________
(EXAM ALTERNATIVE HOURS ONLY)
