rn-en.indd

Packet updated 5/19/23

Please submit a fully completed and signed application along with the required fee and supporting documentation.

Part I: Application Category Information – Complete as follows:

DPR-RN Instructions Revised 3/22

REGISTERED NURSE

Examination

Endorsement

Restoration

INSTRUCTION SHEET

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov

Parts II, III, IV, V:

Record all information requested. Your Social Security Number (SSN) is mandatory. If you do not

have a SSN, you must submit the SSN aﬃ davit. It is available on the Department website at

www.idfpr.com. Include your email address in Part II, Box 12.

Part VI: You must answer each question. An aﬃ rmative response to any of the questions, requires a

detailed, personal statement and documentation.

Part VII: Examination applicants only - Refer to the Reference Sheet.

Part VIII: Both questions must be answered.

Part IX: Application must be signed in ink and dated.

GENERAL INFORMATION

Criminal Background Check: All applicants for initial licensure must submit to a criminal background check and pro-

vide evidence of ﬁ ngerprint processing from the Illinois State Police or its designated agent. See attached “Important

Notice – Criminal Background Check Information” for more information concerning this requirement. Applicants who

hold active licensure in Illinois as a licensed practical nurse do not need to submit to a criminal background check.

Documents in a Foreign Language: All documents in a foreign language must be accompanied by an original, nota-

rized translation that has been transcribed by a person other than the applicant, who is ﬂ uent in both English and the

language of the document(s). The translator shall certify to the above requirements as well as to the accuracy of the

translation.

License Renewal: All Registered Nurses licenses expire on May 31 of every even-number year, regardless of the date

of issuance. Renewal notiﬁ cation postcards are mailed approximately three months prior to the expiration date of your

license.

Three Year Life of Application: You have three years from the date your application is received by the Department or

Continental Testing Service, Inc. to complete the application process. If the process is not completed in three years,

your application will be denied and the fee forfeited. Application fees are non-refundable.

Contact Information: If assistance is needed, please contact:

Examination information - www.continentaltesting.net or by phone at 1-708-354-9911

All other application information – www.idfpr.illinois.gov or by phone at 1-800-560-6420 or TTY 1-866-325-4949

Profession Name:

Profession Code: Licensure Method: Fee:

Registered Nurse 041 Examination

Endorsement

Restoration

Exam - See Reference Sheet

Endorsement - $50.00

Restoration – See RS form

Temporary Permit - $25.00

Registered Nurse - Page 2

1. Apply directly online. Register for the examination online at the Continental

Testing Website at www.continentaltesting.net. Application fee payment

must be made with a credit card.

2. If you are not applying online, all documents and required forms must be

submitted to:

Continental Testing Services, Inc.

P.O. Box 100

LaGrange, Illinois 60525-0100

Application fee payment must be in the form of a certiﬁ ed check, personal

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.

3. Conditions of Application – Applicants have three years from the date of

receipt of the application to complete the application process including

passage of the examination. If the process is not completed in three years,

the application shall be denied, the fee forfeited, and the applicant must

reapply and meet the requirements in eﬀ ect at the time of applications,

including proof of 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 identiﬁ ed

by the Act as not meeting the requirements for licensure by examination.

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 oﬃ cial IDFPR/CTS notiﬁ cation.

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 oﬃ cial date of passing the licensure exam as

inscribed within his/her oﬃ cial 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.

If you received your education in the United States or one of its territories, you

must submit the following documentation:

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;

EXAMINATION

General Examination

Instructions

Practice Pending

Licensure

Practice Under

Supervision

Educated Inside the U.S. or

one of its Territories

c. ED-NUR Form (Certiﬁ cate of Education)--Form must be signed by the

Dean or Director of your nursing education program with school seal

aﬃ xed, indicating graduation from a professional nursing education pro-

gram approved by the Department or have been granted a certiﬁ cate of

completion of pre-licensure requirements from another U.S. jurisdiction,

OR submission of oﬃ cial transcripts with school seal aﬃ xed.

d. Fee--See Reference Sheet - Chart I.

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:

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. A credentials evaluation report of your foreign nursing education from one

of the following Department approved credentialing services:

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

Registered Nurse - Page 3

EXAMINATION (cont'd)

Educated Inside the U.S. or

one of its Territories (cont'd)

Educated Outside the U.S.

or one of its Territories

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

Further, if your ﬁ rst language is not English, you will be required to

submit certiﬁ cation of passage of the Test of English as a Foreign Lan-

guage (TOEFL), or the International English Language Testing System

(IELTS).

e. In lieu of the above, the educational requirement may be met by submission

of proof of issuance of the following original certiﬁ cates from the Commis-

sion on Graduates of Foreign Nursing Schools (CGFNS):

 CGFNS Certiﬁ cate; or

 VisaScreen Program Certiﬁ cate and CT Form (Certiﬁ cation of

Foreign Licensure).

f. Fee--See reference Sheet - Chart I.

1. All documents and forms required for licensure by endorsement must

be submitted to:

Illinois Department of Financial and Professional Regulation

ATTN: Division of Professional Regulation

P.O. Box 7007

Springﬁ eld, 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 theo-

ry and clinical components as required by the Illinois Nurse Practice Act.

Therefore, it is considered to be a correspondence course which is identiﬁ ed

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 appli-

cant 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 (Veriﬁ cation of Employment) form

Registered Nurse - Page 4

- NOTE -

Proof of licensure in your

country of

education shall be

required as a part of the

credentialing process.

EXAMINATION (cont'd)

Educated Outside the U.S.

or one of its Territories (cont'd)

ENDORSEMENT

General Endorsement

Instruction

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)

General Endorsement

Instruction (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

notiﬁ cation that the Department intends to deny licensure, whichever comes ﬁ rst.

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:

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. TP-NUR Form (Temporary Permit);

d. 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 $50 endorsement fee and the $25 temporary permit fee into

one check or money order for $75;

f. Proof of ﬁ ngerprint submission in the form of a copy of the ﬁ ngerprint receipt (if

ﬁ ngerprinted in Illinois), or a completed OOS-FP form if ﬁ ngerptined outside

of Illinois. See the Notice for additional information.

In order to be considered for licensure, applicants who were educated in the United

States or one of its territories must submit the following:

a. Application for Licensure and/or Examination (four page). You need not resubmit

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 (Veriﬁ cation of Licensing Agency/Board)--Submit veriﬁ cation

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;

d. ED-NUR Form (Certiﬁ cate of Education) indicating graduation from a

professional nursing education program approved by the Department; or

the granting of a certiﬁ cate of completion of pre-licensure requirements

from another U.S. jurisdiction. The ED form must be signed by the di-

rector of the nursing education program with the school seal aﬃ xed,

OR oﬃ cial transcripts with school seal aﬃ xed;

e. Fee--See Reference Sheet - Chart I or Page 1.

- Important Notice -

Applicants educated outside

the U.S. or its Territories must

have an acceptable credentials

evaluation report from a

Department-approved

credentials evaluation service

on ﬁ le 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.

Educated Inside U.S. or

one of its Territories

The National Council of State Boards of

Nursing (NCSBN) handles verification

of licensure for many state boards of

nursing who participate in Nursys®.

Please visit Nursys.com (www.nursys.

com) or https://www.nursys.com/NLV/

LicenseVeriﬁ cationJurisdictions.aspx to

view a complete list.

If the state(s) where you have been licensed

as a nurse participates in Nursys®, you must

request veriﬁ cation 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 participating boards

of nursing, you must use the CT-NUR form

(Veriﬁ cation of Licensing Agency/Board)

to verify your license to the Illinois Board

of Nursing.

- IMPORTANT NOTICE -

CERTIFICATION OF LICENSURE

Registered Nurse - Page 6

In order to be considered for licensure, applicants who were educated outside

the United States or one of its territories must submit the following:

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 (Veriﬁ cation of Licensing Agency/Board)--Submit veriﬁ ca-

tion 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.

d. A credentials evaluation report of your foreign nursing education from one

of the following Department approved credentialing services. The credentials

evaluation report must reﬂ ect proof of licensure in the country of education.

 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:

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

Educated Outside U.S. or

its Territories

The National Council of State Boards of

Nursing (NCSBN) handles verification

of licensure for many state boards of

nursing who participate in Nursys®.

Please visit Nursys.com (www.nursys.

com) or https://www.nursys.com/NLV/

LicenseVeriﬁ cationJurisdictions.aspx to

view a complete list.

If the state(s) where you have been licensed

as a nurse participates in Nursys®, you must

request veriﬁ cation 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 participating boards

of nursing, you must use the CT-NUR form

(Veriﬁ cation of Licensing Agency/Board)

to verify your license to the Illinois Board

of Nursing.

- IMPORTANT NOTICE -

CERTIFICATION OF LICENSURE

- NOTE -

Proof of licensure in your

country of

education shall be

required as a part of the

credentialing process.

ENDORSEMENT (cont'd)

Registered Nurse - Page 7

Further, if your ﬁ rst language is not English, you shall be required to submit

certiﬁ cation of passage of the Test of English as a Foreign Language

(TOEFL), or the International English Language Testing System

(IELTS).

e. In lieu of the items in d. above, the educational requirement may be met by

submission of proof of issuance of the following original certiﬁ cates from

the Commission on Graduates of Foreign Nursing Schools (CGFNS):

 CGFNS Certiﬁ cate; or

 VisaScreen Program Certiﬁ cate and CT Form (Certiﬁ cation of

Foreign Licensure)

f. Fee--See Reference Sheet - Chart I or Page 1.

General Restoration

Instructions

To restore a license that has expired or been placed on inactive status for more

than ﬁ ve years please submit all documents and forms required for licensure by

restoration to the following address:

Illinois Department of Financial and Professional Regulation

ATTN: Division of Professional Regulation

P.O. Box 7007

Springﬁ eld, 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 Oﬃ cial 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;

d. CT-NUR Form (Veriﬁ cation of Licensing Agency/Board)--Submit Certiﬁ cation

of active practice in another jurisdiction;

e. VE-Form (Veriﬁ cation of Employment/Experience) - Submit veriﬁ cation of

active practice within the last 5 years;

f. DD214--If restoring after active military service, submit a copy of this form.

g. Proof of completion of 20 hours of continuing education (completed within

two years of the date of the restoration application.)

h. Proof of ﬁ ngerprint submission in the form of a copy of the ﬁ ngerprint receipt

(if ﬁ ngerprinted in Illinois), or a completed OOS-FP form if ﬁ ngerprinted

outside of Illinois. See the Notice for additional information.

Educated Outside U.S. or

its Territories

(cont'd)

ENDORSEMENT (cont'd)

RESTORATION

~IMPORTANT NOTICE~

These Restoration

Instructions apply only to

those registered nurses whose

licenses have been on inactive

status, or in non-renewed

status, for ﬁ ve or more years.

If your license has been

inactive, or in non-renewed

status, for less than ﬁ ve

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.

Registered Nurse - Page 8

NOTE: If unable to provide proof of ﬁ tness to practice nursing via submission

of a VE form substantiating active engagement in nursing practice in

another U.S. jurisdiction within the last ﬁ ve (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 Depart-

ment.

General Restoration

Instructions

(cont'd)

Temporary Permit

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 no-

tiﬁ cation that the Department intends to deny licensure, whichever comes ﬁ rst.

It will be your responsibility to complete the restoration process prior to the

expiration of the temporary permit.

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. Photo copies of all current active Registered 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 veriﬁ cation of employment

in nursing practice within the last ﬁ ve years in a United States jurisdiction;

d. Fee--Combine the restoration fee and the $25 temporary permit fee into

one check or money order.

RESTORATION (cont'd)

This guide will help you complete the forms needed to apply for licensure. For speciﬁ c information regarding the forms

which you will be required to submit, refer to the ﬁ ling instructions relative to the method of licensure under which you

are applying.

Provide all information requested on the four-page application.

1. Part I--Use the Reference Sheet (Chart I) to record the appropriate Profes-

sion Name, 3 digit Profession Code, Licensure Method and Fee;

2. Part II--Enter all applicable information requested. Your Social Security

Number (SSN) is mandatory. If you do not have a SSN, you must submit

the aﬃ davit;

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". Refer to www.ncsbn.org for school code listing;

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.

Application for Licensure

and/or Examination

Registered Nurse - Page 9

FORMS COMPLETION GUIDE

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

Veriﬁ cation 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.

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.

ED-NUR

Certiﬁ cation of Education

Important: The National Council of State Boards of Nursing (NCSBN) handles

veriﬁ cation of licensure for many state boards of nursing who participate in

Nursys®. Please visit Nursys.com (www.nursys.com) or https://www.nursys.

com/NLV/LicenseVeriﬁ cationJurisdictions.aspx to view a complete list.

If the state(s) where you have been licensed as a nurse participates in Nursys®,

you must request veriﬁ cation 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 participating boards of nursing, you must use the CT-NUR

form (Veriﬁ cation of Licensing Agency/Board) to verify your license to the

Illinois Board of Nursing.

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 aﬃ xed.

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.

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 ﬁ ll 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.

This is one of the forms you must complete to restore your Illinois Registered

Nurse license. This form is only available by contacting the Department at

1-800-560-6420.

Proof of ﬁ ngerprint submission receipt (if ﬁ ngerprinted in Illinois) or a

completed OOS-FP form (if ﬁ ngerprinted outside of Illinois).

TP-NUR

Temporary Permit

Veriﬁ cation of

Employment/Experience

Restoration

Registered Nurse - Page 10

CT-NUR

Veriﬁ cation of Licensure (cont'd)

Copies of licenses are not

acceptable in lieu of an oﬃ cial

veriﬁ cation of licensure.

Fingerprint Receipt

OR Certifying Statement of

Fingerprint Submission

OOS-FP Form

FORMS COMPLETION GUIDE (cont'd)

LICENSURE METHODS AND DEFINITIONS

Following are deﬁ nitions 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 speciﬁ c licensure methods/requirements for

your profession.

Licensure Methods Deﬁ nition

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

qualiﬁ cation and practices (for a speciﬁ ed time only).

Non-examination Applicant is licensed by meeting qualiﬁ cations 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, 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

CHART I - PROFESSION NAME, PROFESSION CODE, LICENSURE METHOD & FEE

ALL FEES ARE NONREFUNDABLE

Department reserves the right to change examination dates, ﬁ ling deadlines and fees

if prevailing circumstances necessitate such action.

CHART III - EXAMINATION DATES - Information will be available once you are approved for the exam.

DPR-RN 7/15

REFERENCE SHEET

CHART II - EXAMINATION CODES AND FEES

If assistance is needed, direct your request (based upon your licensure method) to:

* * * * * REQUEST FOR ASSISTANCE * * * * *

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.

See Supporting Document RS

Profession

Code

Licensure

Method

Profession Name

Registered Nurse

RegIstered Nurse

041

Examination (CTS)

Examination (NCSBN)

Endorsement of License

Temporary Permit

Restoration

Temporary Permit

Application

Fee

$50.00

$25.00

Licensure Methods Except Examination (US ONLY)

1-800-560-6420

TTY

1-866-325-4949

Please allow 6 weeks from mailing your application

before making an inquiry concerning its status.

Examination Licensure Method Only

Continental Testing Services, Inc.

1-708-354-9911

* Contact Continental Testing Services, Inc. at www.continentaltesting.net for current fees.

CHART IV - SCHOOL CODES - Refer to www.ncsbn.org for school code listing.

Illinois Department of Financial and Professional Regulation

Division of Professional Regulation

Application Checklist for Registered Nurses

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

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 aﬃ xed; or

Nursing transcripts with seal aﬃ xed.

Credentials of Foreign Education (if applicable)

CT-NUR (Certiﬁ cation of Licensure) Form completed by state of original licensure and

any state in which you have practiced in the last ﬁ ve (5) years.

Veriﬁ cation requested from NURSYS (if applicable)

VE (Veriﬁ cation of Employment) Form (if applicable)

Proof of Name Change (if applicable)

Criminal Background Check

TP-NUR Form (temporary permit only)

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)

IL486-1971 (RN) 6/15

Before you mail your application, check the following items to make sure your application is complete!

All supporting documents may not be required. Please refer to application instructionsfor your speciﬁ c method of licensure.

COMPLETED

SUBMITTED

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. UNITED STATES SOCIAL SECURITY NO.

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

8. PLACE OF BIRTH CITY STATE/COUNTRY

11. 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.

IL486-1019 4/22 (LT)

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

9. 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.

10. AGE

Female

Male

Work: ( __ __ __ ) __ __ __

__ __ __ __ Home: ( __ __ __ ) __ __ __

__ __ __ __

(Area Code) (Area Code)

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4

12.

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov

7. MOTHER'S MAIDEN NAME

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.

Fax: ( __ __ __ ) __ __ __

__ __ __ __ Fax: ( __ __ __ ) __ __ __

__ __ __ __

(Area Code) (Area Code)

REQUIRED

E-MAIL ADDRESS

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.

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

LOCATION

(City and State or Country)

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)

IL486-1019

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

NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________

PART IV: Record of Licensure Information

IL486-1019

(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): ______________________________________________SS#: _____________________ Profession: ___________________

PART VI: Personal History Information (This part must be completed by all applicants)

NOYES

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.

PART IX: Certifying Statement

IL486-1019

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 4 of 4

NAME (Last, First, MI): ______________________________________________ SS#: _____________________ 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

PART VIII: Child Support and Tax Information (Every applicant is required by law to respond to the following

questions)

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 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:

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.

HEALTH CARE WORKERS

CHARGED WITH OR CONVICTED

OF CRIMINAL ACTS

SUPPORTING DOCUMENT

CCA

1. NAME LAST FIRST MIDDLE

2. ADDRESS STREET, CITY, STATE, ZIP CODE

3. PROFESSIONAL LICENSE NUMBER (if any)

__ __ __ - __ __ __ __ __ __

4. SOCIAL SECURITY NUMBER

__ __ __ - __ __ - __ __ __ __

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 06/19 (crimacts)

Signature of Applicant Email Date

Page 1of 3

If YES to any of the above, attach a certiﬁ ed copy of the court records regarding your conviction, 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? *

Yes

Are you currently charged with or have you been convicted of a criminal act that requires registration

under the Sex Oﬀ ender Registration Act? *

Are you currently charged with or have you been convicted of a forcible felony? *

Pursuant to 20ILCS 2105-165(a), the Department requires the following professionals to disclose information regarding convictions

pertaining to certain oﬀ enses. Please check applicable profession.

Advanced Practice Registered Nurses

Acupuncturists

Audiologists

Dental Hygienists

Clinical Psychologists

Clinical Social Workers

Dentists

Athletic Trainers

Marriage and Family Therapists

Licensed Clinical Professional

Counselors

Genetic Counselors

Licensed Social Workers

Medication Aide

Licensed Practical Nurses

Podiatrists

Physician Assistants

Registered Nurses

Speech Pathologists

Respiratory Care Practitioners

Professional Counselors

Registered Surgical Assistants

Registered Surgical Technologists

Prosthetists

Occupational Therapists

Occupational Therapy Assistants

Naprapaths

Pharmacists

Physical Therapists

Physicians, including Medical Doctors (M.D.), Doctors

of Osteopathic Medicine (D.O.), and Chiropractic

Physicians (D.C.)

Physical Therapy Assistants

Nursing Home Administrators

Orthotists

Pedorthists

Optometrists

Perfusionists

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.

Advanced Practice Registered

Nurse - Full Practice Authority

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?

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 moti-

vated 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 at-

tempting 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 Manage-

ment 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 de-

ﬁ 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 intentionally left blank

for double-sided printing.

A. The applicant has written the following examination times.

is scheduled for the following examination on __ __ / __ __ / __ __ __ __

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.

1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH 3. SOCIAL SECURITY NUMBER

Month Day Year

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.

7. APPLICANT TELEPHONE NUMBER (Daytime)6. MAIDEN OR GIVEN SURNAME

Profession Code

7a. RECORD PROFESSION NAME AS IT APPEARS ON YOUR LICENSE

FROM THE JURISDICTION TO WHICH THIS FORM IS BEING FOR-

WARDED.

(If applicable)

7b. LICENSE NUMBER

(If applicable)

7c. 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.

Name of Licensing Agency or Board

PART I. - VERIFICATION OF EXAMINATION STATUS

APPLICANT: Complete the applicant section of this form then forward this form to the state or territory in which

you are requesting veriﬁ cation of your examination status, license or examination scores. Contact

certifying jurisdiction for appropriate fee. Photocopying this form is permissible.

NAME OF EXAMINATION

DATE OF

EXAMINATION

Passed Failed

National Council Licensure Examination

for Registered Nurses (NCLEX-RN)

DATE OF

EXAMINATION

FailedPassed

RESULTS RESULTS

National Council Licensure Examination

for Practical Nurses (NCLEX-PN)

Name of Program

Location of Program

Year of Graduation

Area Code ( )

Profession Name

VERIFICATION BY LICENSING

AGENCY/BOARD

SUPPORTING DOCUMENT

CT-NUR

Signature Date

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.

LICENSING AGENCY:

RETURN COMPLETED FORM TO APPLICANT

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? Yes No

IL486-0307 04/06 (NS)

Month Day Year

B. Nursing Education Program Completed.

CT-NUR - Veriﬁ cation by Licensing Agency/Board - Page 1 of 2

__ __ / __ __ / __ __ __ __

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

B. LICENSE NUMBER

A. NAME OF PROFESSION AS IT APPEARS ON LICENSE

E. LICENSURE METHOD

C. ISSUANCE DATE OF LICENSE D. EXPIRATION DATE OF LICENSE

F. CURRENT LICENSURE STATUS

Examination - Date Endorsement of License (State)

National Council Acceptance of Examination Results

Licensure Examination Administered in Another State

State Constructed Waiver/Grandfather

Other (Name) Other (Describe)

Active Lapsed

Inactive Other (explain)

PSYCHIATRIC

NURSING

OBSTETRIC

NURSING

SURGICAL

NURSING

NURSING OF

CHILDREN

NCLEX/COMP.

EXAM

NCLEX/COMP.

EXAM

REGISTERED NURSE

Standard Scores

Series/Form No.

LPN

MEDICAL

NURSING

N.S.B.T.P.E.

RESULTS

B. State Constructed Examination Registered Nurse Licensed Practical Nurse

SUBJECT SCORE SUBJECT SCORE

PART IV. - FORMAL ACTIONS

PART V. - ADDITIONAL INFORMATION

I certify that the information contained herein is true and correct according to the oﬃ cial records of the State.

Print Name

Title Signature

Agency/Board Street Address Date

Area Code ( )

City, State, ZIP Code Telephone Number

S E A L

A. National

PART III. - VERIFICATION OF EXAMINATION SCORES

PART II. - VERIFICATION OF LICENSURE

IL486-0307 04/06 (NS)

Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT.

Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.

CT-NUR - Veriﬁ cation by Licensing Agency/Board - Page 2 of 2

NAME (Last, First, MI): _____________________________________________ SS#: _____________________ Profession: ___________________

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.

Signature of ApplicantDate

IL486-1031 05/14 (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

Total calendar years attended

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 - Certiﬁ cation of Education - Page 1 of 2

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.

NCSBN Number

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

I certify that the educational information recorded herein is true and correct according to the oﬃ cial records of this

institution.

Print Name of Dean or Director of Nursing License Number

Date

Signature of Dean or Director of Nursing

Title

IL486-1031 05/14 (NS) ED-NUR - Certiﬁ cation of Education - Page 2 of 2

NAME (Last, First, MI): ______________________________________________ SS#: _____________________ Profession: ___________________

SCHOOL SEAL OR NOTARY SEAL

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

SUPPORTING DOCUMENT

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

6. MAIDEN OR GIVEN SURNAME

4. ADDRESS STREET, CITY, STATE, ZIP CODE

8. DATES OF EMPLOYMENT

From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __

Month Day Year Month Day Year

2. DATE OF BIRTH

3. SOCIAL SECURITY NUMBER

5. REFER TO REFERENCE SHEET. Record profession name and

three digit profession code for which you are making Illinois application.

7. JOB TITLE OR POSITION APPLICANT HELD

9. SUPERVISOR NAME

___ ___ ___

Profession Name Profession Code

EMPLOYER: Complete the remainder of this form. Return the completed form to the applicant in a sealed

envelope.

PART I - EMPLOYMENT INFORMATION

A. EMPLOYER NAME

C. EMPLOYER REGISTRATION/LI-

CENSE NUMBER

F. BUSINESS REGISTRATION/LI-

CENSE NUMBER (If Applicable)

PART II - APPLICANT EMPLOYMENT INFORMATION

A. NUMBER OF HOURS WORKED

PER WEEK

B. BUSINESS / INSTITUTION NAME

E. BUSINESS ADDRESS STREET CITY STATE ZIP CODE

H. BUSINESS TELEPHONE NUMBER

C. DATES OF EMPLOYMENT

G. STATE OF BUSINESS

REGISTRATION/LICENSE

D. STATE OF EMPLOYER

REGISTRATION/LICENSE

B. TYPE OF EMPLOYMENT

Area Code (___ ___ ___) ___ ___ ___

___ ___ ___ ___

[ ]Full-time [ ]Part-time

E. GIVE BRIEF DESCRIPTION OF DUTIES PERFORMED BY THE APPLICANT.

D. RECORD APPLICANT'S POSITION TITLE(S)

I do hereby declare that this information is true and correct.

Signature

TitleDate

IL486-1348 04/06 (L&T)

__ __ __ - __ __ - __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __

Month Day Year Month Day Year

1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH 3. SOCIAL SECURITY NUMBER

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.

Profession Name

This form must be completed in its entirety and accompanied by the four (4) page application jacket.

APPLICANT:

6. MAIDEN OR GIVEN SURNAME

7. Nursing Education Program Completed.

NAME OF EXAMINATION

DATE OF

EXAMINATION Passed Failed

DATE OF

EXAMINATION

FailedPassed

RESULTS RESULTS

National Council Licensure Examination

for Practical Nurses (NCLEX-PN)

National Council Licensure Examination

for Registered Nurses (NCLEX-RN)

Other:

Name of Program

Location of Program

Year of Graduation

8. Licensure examination taken in your state of original licensure which was the basis for your initial licensure:

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 ﬁ ve (5) years?

Yes No If so, submit certiﬁ ed 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 ﬁ ve (5) years? Yes No

If so, have appropriate board of nursing complete CT-NUR form and attach copies of disciplinary action.

Profession Code

Signature Date

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.

IL486-1577 12/00 (NS)

TEMPORARY PERMIT

SUPPORTING DOCUMENT

TP-NUR

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.

Individuals applying for licensure for professions that require ﬁ ngerprints must submit to a criminal

background check and provide evidence of ﬁ ngerprint processing from a ﬁ ngerprint 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.

IMPORTANT NOTICE

CRIMINAL BACKGROUND CHECK INFORMATION

Applicants may contact a licensed  ngerprint vendor to schedule an appointment for  ngerprinting

by going to https://idfprapps.illinois.gov/licenselookup/ ngerprintlist.asp.  e Illinois State Police

will transmit electronic results of  ngerprint processing to the Department. A receipt issued by a

licensed  ngerprint vendor agency must be submitted with the application fee.  e receipt shall be

issued by the  ngerprint vendor at the time the  ngerprints are obtained.

Out-of-State applicants who are unable to schedule an appointment for  ngerprinting through a

licensed  ngerprint vendor need to complete the following steps:



PRIVACY STATEMENT

IL486-2052 NEW 5/23

Authority: The FBl’s acquisition, preservation, and exchange of ﬁ ngerprints and associated information is

generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental

authorities include Federal statutes, State statutes pursuant to Pub.L. 92-544, Presidential Executive Orders, and

federal regulations. Providing your ﬁ ngerprints and associated information is voluntary; however, failure to do

so may aﬀ ect completion or approval of your application.

Go to www.idfpr.illinois.gov to select a licensed  ngerprint vendor that has “Card Scan”

capability. Contact the vendor to determine the fee for a “Card Scan”.

Mail the original Identity Veriﬁ cation Certifying Statement (with Sections 1 and 2

completed), Fee Applicant card and  ngerprint fee to the licensed  ngerprint vendor selected

from the Division of Professional Regulation website.

Mail the completed application, licensing fee and a copy of the Identity Veriﬁ cation Certifying

Statement (with Sections 1 and 2 completed) to the Division of Professional Regulation.



Complete Section 1 of the Identity Veriﬁ cation Certifying Statement form.

Have your prints taken by a police department in another state to obtain classiﬁ able prints,

using an FBI print card.

Section 2 of the Identity Veriﬁ cation Certifying Statement shall be completed and signed

by the police department.

--- Continued on next page ---

PRIVACY STATEMENT - Continued

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be

predicated on ﬁ ngerprint-based background checks. Your ﬁ ngerprints and associated information/biometrics

may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the

purpose of comparing your ﬁ ngerprints to other ﬁ ngerprints in the FBl’s Next Generation Identiﬁ cation {NGI)

system or its successor systems (including civil, criminal, and latent ﬁ ngerprint repositories) or other available

records of the employing, investigating, or otherwise responsible agency. The FBI may retain your ﬁ ngerprints

and associated information/biometrics in NGI after the completion of this application and, while retained, your

ﬁ ngerprints may continue to be compared against other ﬁ ngerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your ﬁ ngerprints and

associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your

consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable

Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI

system and the FBl’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to:

employing, governmental or authorized non-governmental agencies responsible for employment, contracting,

licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law

enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Applicant Notiﬁ cation and Record Challenge

Your ﬁ ngerprints will be used to check the criminal history records of the FBI. You have the opportunity to

complete or challenge the accuracy of the information contained in the FBI identiﬁ cation record. The procedure

for obtaining a change, correction, or updating an FBI identiﬁ cation record are set forth in Title 28, CFR, 16.34.

You can ﬁ nd additional information on the FBI website at https://www.fbi.gov/about-us/cjis/background-checks.

I, the undersigned, hereby authorize the release of any criminal history record information that may exist

regarding myself from any agency, organization, institution, or entity having such information on ﬁ le. I am

aware and understand that my ﬁ ngerprints may be retained and will be used to check the criminal history record

information ﬁ les of the Illinois State Police and/or Federal Bureau of Investigation. I also understand that if my

photo was taken, my photo may be shared only for employment of licensing purposes.

___________________________________________ _________________________

Original Signature of Applicant Today’s Date

ACKNOWLEDGMENT

IL486-2052 NEW

IDENTITY VERIFICATION CERTIFYING

STATEMENT

OOS-FP

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.

Pursuant to Title 68 Part 1240.535 of the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and

Locksmith Act of 2004 Rules, ﬁ ngerprint vendors are required to conﬁ rm identity of the individual seeking to be ﬁ nger-

printed. This identity veriﬁ cation form must be completed for out-of-state residents applying for licensure/employment in

the State of Illinois. This form will be utilized to conﬁ rm the personal identifying information being placed on the Illinois

State Police (ISP) Fee Applicant ﬁ ngerprint card, form number ISP-404. The out-of-state agency chosen to take your

ﬁ ngerprints, must complete this form, as written conﬁ rmation that a valid government issued drivers license or State ID

was presented and that the identiﬁ cation provided, belongs to the individual being ﬁ ngerprinted.

Instructions: This form must be submitted, along with a manual Fee Applicant ﬁ ngerprint card to which your ﬁ nger-

prints have been applied, to a licensed live scan ﬁ ngerprint vendor in the State of Illinois possessing “Scan Card” capa-

bility to ensure electronic transmission of the Fee Applicant ﬁ ngerprint card. The electronic transmission of ﬁ ngerprints

to the ISP is mandated pursuant to Title 20 Part 1265 “Electronic Transmission of Fingerprints”. The manual submis-

sion of ﬁ ngerprints to ISP is no longer acceptable. Once your ﬁ ngerprints have been taken, a signed original of this

form must be attached to your Fee Applicant ﬁ ngerprint card and submitted to an Illinois licensed live scan ﬁ ngerprint

vendor. As well, an additional copy may be required to be submitted to the requesting State Agency along with any ad-

ditional application or required documentation speciﬁ ed by the State Agency.

Section 2 Certifying Agency Taking Fingerprints (Include TCN from Fee Applicant card)

Section 3 Fingerprint Vendor Agency Name

Illinois Live Scan Fingerprint Vendor Information

AGENCY NAME:

TCN: FRM

DATE FINGERPRINT TAKEN: CONTACT PHONE NUMBER:

/ /

( ) -

PRINTING AGENT’S NAME: LAST FIRST

I have compared the government issued identiﬁ cation presented by the applicant and attest that to the

best determination, I have ﬁ ngerprinted the same individual. (Must be checked to certify)

PRINTING AGENT’S SIGNATURE:

LIVE SCAN FP AGENCY NAME:

REQUESTING STATE AGENCY: REQUESTING STATE AGENCY ORI:

DATE FINGERPRINTS SUBMITTED TO ISP:

COST CENTER USED:

IL486-2222 4/15

Section 1 Applicant Information (All ﬁ elds mandatory)

MAIDEN NAME/GIVEN SURNAME:

ADDRESS: (STREET/CITY/STATE/ZIP)

LAST NAME: FIRST: MIDDLE:

POSITION / REASON FINGERPRINTED: (NURSE/DOCTOR/SECURITY GUARD, ETC)

SOCIAL SECURITY NUMBER:DATE OF BIRTH:

PHONE NUMBER:

IL486-2274 6/16

AUTHORIZATION FOR THIRD PARTY CONTACT

ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION

Name:

Address:

Profession:

I, ____________________________________, hereby authorize the following person/business to

communicate with the Division regarding my application for initial licensure. I understand that information

received from the person or business listed below shall be binding and that I will be responsible for the

accuracy of all information and documents received as part of my application for initial licensure. This

authorization shall expire upon issuance of the license, referral to enforcement or expiration of the application.

Name of authorized representative:

Address:

Phone:

Email:

Applicant Signature Date

Completed forms may be sent to the Division at:

[email protected]

Instructions to Applicant: Use this form to authorize individuals or companies (such as employers or

credential services) to contact the Department on your behalf regarding your application.

Phone:

SSN:

Email:

NURSING