I hereby authorize a school official of the institution named above to furnish to the Illinois Department of Professional Regu-
lation or its designated testing service the information requested below.
Signature of ApplicantDate
IL486-1031 07/02 (NS)
APPLICANT: Complete the applicant section of this form, then forward it to the school for completion of the
remainder of the form.
SCHOOL OFFICIAL: Complete the bottom portion of this page and the reverse side, then return to the
applicant.
From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __
Total academic years attended
OR
Total calendar years attended
F.
Years Months Days
Years Months Days
CERTIFICATION OF EDUCATION
SUPPORTING DOCUMENT
ED-NUR
Profession Name Profession Code
6. MAIDEN OR GIVEN SURNAME
7. NAME OF INSTITUTION ATTENDED
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.
8. DATE OF GRADUATION/COMPLETION
A. NAME OF INSTITUTION
C.DEPARTMENT OF INSTITUTION
D.MAJOR AREA OF STUDY OF THE APPLICANT
H. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS WERE MET
J. IF EDUCATION PROGRAM WAS COMPLETED IN LESS THAN THE NORMALLY REQUIRED TIME, PLEASE EXPLAIN:
B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE
E. DATES OF ATTENDANCE
G.TYPE OF DEGREE OR CERTIFICATE AWARDED (e.g., BA., MA.,
Ph.D.)
I. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED
1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH 3. SOCIAL SECURITY NUMBER
ED-NUR - Certification of Education - Page 1 of 2
Month Day Year
__ __ / __ __ / __ __ __ __
Month Day Year
__ __ / __ __ / __ __ __ __
Month Day Year
Month Day Year
Month Day Year
__ __ / __ __ / __ __ __ __
Month 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.
SUBMISSION OF THIS FORM PRIOR TO PROGRAM COMPLETION WILL RESULT IN ITS RETURN TO THE
PROGRAM FOR CORRECTION.
Subscribed and sworn before me this ______day of_________________, 20____.
NOTE: If the institution does not have a school seal, this form must be notarized.
Date of Expiration
Signature of Notary Public
RETURN THIS FORM TO APPLICANT
K. NURSING SCHOOL PROGRAM CODE
NCSBN Number
I certify that the educational information recorded herein is true and correct according to the official records of this institu-
tion.
Print Name of Dean or Director of Nursing License Number
Date
Signature of Dean or Director of Nursing
Title
IL486-1031 07/02 (NS)
ED-NUR - Certification of Education - Page 2 of 2
NAME (Last, First, MI):
______________________________________________
SS#:
_____________________
Profession:
___________________
SCHOOL SEAL OR NOTARY SEAL
