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INSTRUCTION SHEET

REGISTERED NURSE

Examination Endorsement Restoration

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

In accordance with the Illinois Nurse Practice Act, "For the protection of life and the promotion of health, and the prevention ofillnessandcommunicablediseases,anypersonpracticingorofferingtopracticeprofessionalandpracticalnursinginIllinois shallsubmitevidencethatheorsheisqualifiedtopractice,andshallbelicensedashereinafterprovided."AcopyoftheIllinois Nurse Practice Act and the Rules can be downloaded from the IDFPR Web Site at www.idfpr.com. If you are issued a registered nurse license, please be advised that your license will expire on May 31st of every even-numbered year.

		Page
Table of Contents	Applying for Licensure	2
	General Instructions	2
	Examination	2
	GeneralExaminationInstructions	2
	Practice Pending Licensure	3
	Practice Under Supervision	3
	Educated Inside U.S. or one of its Territories	3
	Educated Outside U.S. or one of its Territories	4
	Endorsement	5
	General Endorsement Instructions	5
	Temporary Permit	6
	Educated Inside U.S. or one of its Territories	6
	Educated Outside U.S. or one of its Territories	7
	Restoration	8
	General Restoration Instructions	8
	Temporary Permit	9
	Forms Completion Guide	10-11

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

DPR-RN Instructions Revised 12/12

Packet updated 10/1/13

APPLYING FOR LICENSURE

General Instructions	1.	Apply Directly On-Line. Register for the examination by referring to the
		Continental Testing Web site (www.continentaltesting.net) for information
		onhowtoapplyfortheexaminationon-lineandpaythetestfeebycreditcard.
		If you are licensed in another U.S. jurisdiction based on passage of the
		national licensing examination, you are not an "examination" applicant.
	2.	Readtheseinstructions,thenreadtheFilingInstructionsrelatedtothemethod
		of application under which you qualify to determine the documentation and
		forms you must submit. The methods under which you may file to obtain a
		license as a registered nurse are:
		a.	Examination
		b.	Endorsement
		c.	Restoration
	3.	Allindividualsapplyingforinitiallicensureand/orrestorationasaregistered
		nurse in Illinois must submit to a criminal background check and provide
		evidence of fingerprint processing from the Illinois State Police, or its
		designated agent. See attached "Important Notice--Criminal
		Background Check Requirement" for more information concerning this
		requirement.
		Note: TheCriminalBackgroundCheckRequirementdoesnotapplytothose
			applicantsmakingapplicationforregisterednurseexamination/licensure
			who are licensed in Illinois as a licensed practical nurse.
	4. All documents in a foreign language must be accompanied by an original,
		notarized translation that has been transcribed by a person other than the
		applicant,whoisfluentinbothEnglishandthelanguageofthedocuments(s).
		The translator shall certify to the above requirements as well as to the
		accuracy of the translation.
	5.	Forinformationconcerningthecompletionofanyoftheenclosedforms,refer
		totheFormsCompletionGuideonpages10and11.Youmayphotocopyany
		of the enclosed forms if additional forms are needed.

6. If needed, a telephone number for assistance in completing the Application Package is indicated on the REFERENCE SHEET.

EXAMINATION

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

General Examination	1. Read the above General Instructions before proceeding. All documents and
Instructions	forms required for licensure by examination must be submitted to:
	Continental Testing Services Inc.
	P.O. Box 100
	LaGrange,Illinois60525-0100
	2. Application fee payment must be in the form of a certified check or money
	order made payable to Continental Testing Services, Inc. A separate
	examination registration fee will be paid at the actual time of registration as
	noted in Chart II on the Reference Sheet. To determine the fees, see the
	Reference Sheet, Chart I and II.

RegisteredNurse-Page2

EXAMINATION (cont'd)

General Examination Instructions (cont'd)

3.Conditions of Application--Applicants have three years from the date of the Department's receipt of the application to complete the application process including passage of examination. If the process has not been completedinthreeyears,theapplicationshallbedenied,thefeeforfeited,and the applicant must reapply and meet the requirements in effect at the time of application, including proof of the successful completion of at least 2 additional years of professional nursing education.

NOTE: Excelsior College is an unapproved nursing education program in the State of Illinois due to the fact that it does not have concurrent theory and clinical components as required by the Illinois Nurse Practice Act. Therefore, it is considered to be a correspondence course which is identified by the Act as not meeting the requirements for licensure.

Practice Pending	Pursuant to Public Act 95-0639, you are prohibited from practicing until such
Licensure	time as you have completed and passed the Department approved licensure
	examination and are in receipt of official IDFPR/CTS notification.

Practice Under Supervision

Pursuant to 60-10(d)(e) of the Illinois Nurse Practice Act, an applicant may practice as a license-pending registered nurse under direct supervision for a period of three months from the official date of passing the licensure exam as inscribed within his/her official formal pass letter. No applicant for licensure practice under the provisions of this paragraph shall practice license-pending except under the direction of a registered professional nurse or an advanced practice nurse licensed under this Act. In no instance shall any such applicant practice or be employed in any management capacity.

Educated Inside the U.S. or one of its Territories

- IMPORTANT NOTICE -

w w w . n u r s y s . c o m / N L V / LicenseVerificationJurisdictions.aspx to

view a complete list.

If the state(s) where you have been licensed as a nurse licensure participates in Nursys®, you must request verification of your licensure through Nursys® (www.nursys.com), not the state(s). If your state(s) of licensure does not appear on the Nursys® list of licensure participating boards of nursing, you must use the CT-NUR form (Verification of Licensing Agency/Board) to verify your license to the Illinois Board of Nursing.

If you received your education in the United States or one of its territories, you must submit the following documentation (read the General Instructions and the GeneralExaminationInstructionsonpage2now,ifyouhavenotalreadydoneso):

a.Application for Licensure and/or Examination (four-page);

b.CT-NUR Form (Verification of Licensing Agency/Board)--Submit a verifica- 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. Verification of licensure for an LPN license held in another jurisdiction within the last 5 years will only be required if you were not subsequently licensed in the same jurisdiction as an RN.

You must direct the appropriate licensing agency(s)/board(s) to return the completed form directly to you to be submitted with your application.

c.ED-NUR Form (Certificate of Education)--Form must be signed by the Dean or Director of your nursing education program with school seal affixed, indicating graduation from a professional nursing education program approved by the Department or have been granted a certificate of completion of pre- licensure requirements from another U.S. jurisdiction;

d.Fee--See page 2, General Examination Instructions, paragraph 2.

RegisteredNurse-Page3

EXAMINATION (cont'd)

Educated Outside the U.S. or one of its Territories

- IMPORTANT NOTICE -

The National Council of State Boards of Nursing (NCSBN) handles verification of licensureformanystateboardsofnursingwho licensure participate in Nursys®. Please visit Nursys.com (www.nursys.com) or https:// w w w . n u r s y s . c o m / N L V / LicenseVerificationJurisdictions.aspx to view a complete list.

- NOTE -

Proof of licensure in your

countryof

education shall be

required as a part of the credentialing process.

In order to be considered for licensure, applicants who received their education outside the United States or one of its territories must submit the following (read the General Instructions and the General Examination Instructions on page 2 now, if you have not yet done so):

a.Supporting Document CCA must be completed and submitted with each application. Your application will not be processed without completion of this form.

b.Application for Licensure and/or Examination (four page);

c.CT-NURForm(VerificationofLicensingAgency/Board)--Submitaverification of licensure from the state of original licensure, current state of licensure and any jurisdiction in which you have actively practiced within the last 5 years. Verification of licensure for an LPN license held in another jurisdiction within the last 5 years will only be required if you were not subsequently licensed in the same jurisdiction as an RN;

You must direct the appropriate licensing agency(s)/board(s) to return the completed form directly to you to be submitted with your application.

d.Submit the following proof of education:

1.A credentials evaluation report of your foreign nursing education from a Department approved credentialing service. One such service is the Commission on Graduates of Foreign Nursing Schools (CGFNS) Creden- tials 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 EvaluationService

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 approvedbytheDivisionasanursingeducationalcredentialingagency.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: edu@eres.com

Web site: http://www.eres.com

Further, if your first language is not English, you shall be required to submit certification of passage of the Test of English as a Foreign Language (TOEFL). The minimum passing score on the paper-based test is 560. The minimum passing score on the computer-based test is 220. The minimum

RegisteredNurse-Page4

EXAMINATION (cont'd)

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

Education Outside the U.S. or one of its Territories (cont'd)

passing score on the internet-based test is 83.

TOEFL scores previously considered as "passing" scores will be accepted for a period of two years from the date of passage.

e.In lieu of the above, the educational requirement may be met by submission of proof issuance of the following original certificates from the Commission on Graduates of Foreign Nursing Schools (CGFNS):

CGFNS Certificate

VisaScreen Program Certificate

f.Fee--See page 2, General Examination Instructions, paragraph 2.

ENDORSEMENT

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

General Endorsement Instruction

1.Read the Applying for Licensure, General Instructions on page 2 before proceeding. All documents and forms required for licensure by endorse- ment must be submitted as a packet to:

Illinois Department of Financial and Professional Regulation ATTN: Division of Professional Regulation

P.O. Box 7007 Springfield,IL62791

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).

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 (Verification of Employment) form verifying two full years of clinical practice as a registered nurse. This must be submitted with the endorsement application. When the application is complete, it is reviewed by the Board of Nursing for a determination of eligibility to be rendered.

RegisteredNurse-Page5

ENDORSEMENT (cont'd)

Temporary Permit

- Important Notice -

Applicantseducatedoutsidethe U.S. or its Territories must have anacceptablecredentials evaluation report from a Department-approved credentialsevaluationservice on file with the Department indicating their nursing education is comparable to an entry-levelregistered professionalnursingeducation program in the United States prior to being deemed eligible for a temporary permit.

In accordance with Section 60-10(f)(g) of the Illinois Nurse Practice Act, you may be eligible to receive a temporary permit. The permit is valid for six months from the date of issuance, or issuance of an Illinois Registered Nurse License, or notification that the Department intends to deny licensure, whichever comes first. It will be your responsibility to complete the endorsement licensure process prior to the expiration of the temporary permit. In order to receive the permit, submit the following forms and documentation (read the General Instruc- tionsonPage2andtheGeneralEndorsementInstructionsabovenow,ifyouhavenotyetdone so):

a.Supporting Document CCA must be completed and submitted with each application. Your application will not be processed without completion of this form.

b.Application for Licensure and/or Examination (four page);

c.TP-NURForm(TemporaryPermit);

d.PhotostaticcopiesofallcurrentactiveRegistered/LicensedPracticalNurselicensesand/ ortemporarypermits/licensesheldbyyouinanyotherjurisdiction(s)oftheUnitedStates. Currentlicensurein at least one other jurisdiction of the United States is required by the Illinois Nursing and Advanced Practice Nursing Act;

e.Fee--Combinetheendorsementfeeandthetemporary permitfeeintoonecheckormoney order. (See page 5, General Endorsement Instructions, paragraph 2, for additional information.)

f.Proofoffingerprintsubmissionintheformofacopyofthefingerprintreceipt(forIllinois graduatesorIllinoisresidents),oracompletedFP-NURformforout-of-stateandforeign- educated applicants.

Educated Inside U.S. or one of its Territories

- IMPORTANT NOTICE -

CERTIFICATIONOFLICENSURE

In order to be considered for licensure, applicants who were educated in the United States or one of its territories must submit the following: (read the General Instructions on Page 2 and the General Endorsement Instructions on page 5 now, if you have not yet done so):

a.Supporting Document CCA must be completed and submitted with each application. Your application will not be processed without completion of this form.

b.ApplicationforLicensureand/orExamination(fourpage).Youneednotresubmitthisform if you previously applied for a temporary endorsement permit;

c.CT-NURForm(VerificationofLicensingAgency/Board--Submitverificationoflicensure fromthestateoforiginallicensure,currentstateoflicensureandanyjurisdictioninwhich you have actively practiced within the last 5 years. Verification of licensure for an LPN licenseheldinanotherjurisdictionwithinthelast5yearswillonlyberequiredifyouwere not subsequently licensed in the same jurisdiction as an RN. Current registration in another state is required by the Illinois Nurse Practice Act. You must direct the licensing agency/board to return the completed form to you to be submitted with your application.

d.ED-NUR Form (Certificate of Education) indicating graduation from a professional nursing education program approved by the Department; or the granting of a certificate ofcompletionofpre-licensurerequirementsfromanotherU.S.jurisdiction.TheEDform must be signed by the director of the nursing education program with the school seal affixed.

e.Fee--See General Endorsement Instructions, page 5, paragraph 2.

RegisteredNurse-Page6

ENDORSEMENT (cont'd)

Educated Outside U.S. or its Territories

- IMPORTANT NOTICE -

CERTIFICATIONOFLICENSURE

- NOTE -

Proof of licensure in your

countryof

education shall be

required as a part of the credentialing process.

In order to be considered for licensure, applicants who were educated outside the United States or one of its territories must submit the following (read the General Instructions on Page 2 and the General Endorsement Instructions on page 5 now, if you have not yet done so):

a.Application for Licensure and/or Examination (four page). You need not submit this form if you previously applied for a temporary endorsement permit;

b.SupportingDocumentCCAmustbecompletedandsubmittedwitheachapplication. Your application will not be processed without completion of this form.

c.CT-NUR Form (Verification of Licensing Agency/Board)--Submit verification of licensure from the state of original licensure, current state of licensure and any jurisdiction in which you have actively practiced within the last 5 years. Current registrationinanotherstateisrequiredbytheIllinoisNursingandAdvancedPractice Nursing Act. Verification of licensure for an LPN license held in another jurisdiction within the last 5 years will only be required if you were not subsequently licensed in the same jurisdiction as an RN.

You must direct the licensing agency/board to return the completed form to you to be submitted with your application.

d.Requestthefollowingproofofeducationtobepreparedforandmakeavailabletothe Department:

1.A credentials evaluation report of your foreign nursing education from a Department approved credentialing service. The credentials evaluation report must reflect proof of licensure in the country of education. One such service is the Commission on Graduates of Foreign Nursing Schools (CGFNS)CredentialsEvaluationService(CES).Therequiredreportis

theHealthcare Profession&ScienceCourse-by-CourseReport.

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:

CredentialsEvaluationService

CGFNS/ICHP

3600MarketStreet,Suite400 Philadelphia,PA19104-2651 Telephone#215/349-8767

Website:http://www.cgfns.org

Additionally,theEducationalRecordsEvaluationservice(ERES)hasbeenapproved 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 downloadedfromERESwhenavailable.

You may contact ERES as follows:

EducationalRecordsEvaluationService,Inc.

601 University Avenue, Suite 127 Sacramento,CA95825 Telephone#916/921-0790

Email:edu@eres.com

Website:http://www.eres.com

RegisteredNurse-Page7

ENDORSEMENT (cont'd)

Educated Outside U.S. or its Territories (cont'd)

TOEFLscorespreviouslyconsideredas"passing"scoreswillbeacceptedfor a period of two years from the date of passage.

CGFNS Certificate

VisaScreen Program Certificate

f.Fee--See page 5, General Endorsement Instructions, paragraph 2.

RESTORATION

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

General Restoration	Do the following if you wish to apply for the restoration of your license because it
Instructions	has expired or been placed on inactive status for more than five years. Read the
	General Instructions on Page 2 before proceeding. All documents and forms
	required for licensure by restoration must be submitted to the following address:
	Illinois Department of Financial and Professional Regulation
	ATTN: Division of Professional Regulation
	P.O. Box 7007
	Springfield,Illinois62791
	Fee payment must be in the form of a check or money order made payable to the
	Department of Financial and Professional Regulation. (See the Official Use Only
	Box on supporting document RS (Restoration), for the fee amount you must
	submit.)
	Submit the following documents and/or forms:
	a. Application for Licensure and/or Examination (four page);
	b. Supporting Ducument CCA must be completed and submitted with each
	application. Your application will not be processed without completion of this
	form.
	c. RSForm(Restoration)--Ifthisformwasnotincludedintheapplicationpacket,
	youmustobtainonebycontactingtheDepartmentofFinancialandProfessional
	Regulationat217-782-0458;

RegisteredNurse-Page8

RESTORATION (cont'd)

General Restoration

Instructions (cont'd)

~IMPORTANTNOTICE~

These Restoration Instructions apply only to those registered nurses whose licenses have been on inactive status, or in non-renewed status, for five or more years.

If your license has been inactive, or in non-renewed status, for less than five years, you should contact the Department of Financial and Professional Regulation at 217/782-0458 for detailed instructions on how to restore it to active status.

d.CT-NURForm(VerificationofLicensingAgency/Board)--Submitverifica- 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. VerificationoflicensureforanLPNlicenseheldinanotherjurisdiction within the last 5 years will only be required if you were not subsequently licensed in the same jurisdiction as an RN.You must direct the licensing agency/board to return the completed form to you to be submitted with your application.

e.VE Form (Verification of Employment/Experience)--This form must be completed by the Personnel Representative for Nursing Services of your place of employment and returned to the Department of Financial and Professional Regulation, Division of Professional Regulation in a sealed envelope.

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

NOTE: If unable to provide proof of fitness to practice nursing via submission of a VE form substantiating active engagement in nursing practice in another U.S. jurisdiction within the last five (5) years, persons making application for restoration of license shall be required to successfully complete the Department-approved licensure examination (NCLEX) prior to the restoration of their license. You must apply directly to the Department; information to facilitate the exam process will be provided once the application has been reviewed and evaluated by the Depart- ment.

Temporary Permit	InaccordancewithSection60-25(b)(e)oftheIllinoisNursePracticeAct,youmay
	apply for a temporary permit. The permit is valid for six (6) months from the date
	ofissuance,orre-issuanceofapermanentlicensebyrestorationornotificationthat
	the Department intends to deny licensure, whichever comes first. It will be your
	responsibility to complete the restoration process prior to the expiration of the
	temporary permit. If eligible, the permit will be issued within fourteen days of
	receipt of a complete application.
	In order to receive the permit, submit the following forms and documentation:
	a.	Application for Licensure and/or Examination (four page);
	a. Supporting Document CCA must be completed and submitted with each
		application.Yourapplicationwillnotbeprocessedwithoutcompletionofthis
		form.
	b. TP-NUR form (Temporary Permit);
	c.	Photostatic copies of all current active Registered/Licensed Practical Nurse
		licenses and/or temporary permits/licenses held by you in any other U.S.
		jurisdiction(s). Current licensure in at least one other jurisdiction of the
		United States is required by the Illinois Nurse Practice Act, or verification
		of employment in nursing practice within the last five years in a United States
		jurisdiction;

d. Fee--Combine the restoration fee and the temporary permit fee into one check or money order.

RegisteredNurse-Page9

FORMS COMPLETION GUIDE

Thisguidewillhelpyoucompletetheformsneededtoapplyforlicensure.Forspecificinformationregardingtheformswhich youwillberequiredtosubmit,refertothefilinginstructionsrelativetothemethodoflicensureunderwhichyouareapplying.

Application for Licensure	Provideallapplicableinformationrequestedonallfourpagesoftheapplication.
and/or Examination	The following will assist you in this endeavor.
	1.	Part 1--Use the Reference Sheet (Chart I) to record the appropriate
		Profession Name, 3 digit Profession Code, Licensure Method and Fee;
	2.	Part II--Enter all applicable information requested. On number 3, Social
		Security Number is mandatory;
	3.	Part III, number 6--Itemize all university/college coursework, including
		nursing education since graduation from high school. Please indicate
		beginning and ending dates by year;
	4.	Part IV--Record of Licensure Information. Individuals licensed in a U.S.
		jurisdiction or a foreign country or province must state whether or not they
		have ever held licensure (either permanent or temporary) to practice as a
		registered nurse or licensed practical nurse;
	5.	Part V--You must indicate type, dates, and results for any and all nurse
		examinations taken (i.e., NCLEX-RN);
	6.	Part VI--This part must be completed by all applicants;
	7.	Part VII--Graduates of Illinois Nursing Education Programs must indicate
		school code in item "c." (See Reference Sheet, Chart IV.) All other
		applicants indicate "See ED-NUR" in the space provided for school code;
	8.	Part VIII--This part must be completed by all applicants;
	9.	Part IX--Read the certifying statement and then sign and date your
		application.

RegisteredNurse-Page10

FORMS COMPLETION GUIDE (cont'd)

CCA

Health Care Workers

Charged With Or Convicted

Of Criminal Acts

This Document MUST be completed and submitted with each application. Your application will not be processed without completion/receipt of this form.

CT-NUR

Verification of Licensure

Copies of licenses are not

acceptable in lieu of an official

verificationoflicensure.

This document must be completed by the licensing jurisdiction(s) of original licensure, currentstateoflicensureandanyjurisdictioninwhichyouhaveactivelypracticedwithin thelast5years.VerificationoflicensureforapreviouslyheldLPNlicensewithinthelast 5yearswillonlyberequiredifyouwerenotsubsequentlylicensedinthesamejurisdiction as an RN.

Complete applicantsectionofform;thensendformtoeachstateorterritoryinwhichyou haveeverheldregisteredorpracticalnurselicensure.CompletionofCT-NURformisnot necessary if license is held in Illinois. Direct the licensing agency/board to return the completed form to you and submit it with your application for licensure and/or examina- tion.

Important:TheNationalCouncilofStateBoardsofNursing(NCSBN)handlesverification of licensure for many state boards of nursing who licensure participate in Nursys®. Please visit Nursys.com (www.nursys.com) or https://www.nursys.com/NLV/ LicenseVerificationJurisdictions.aspxtoviewacompletelist.

If the state(s) where you have been licensed as a nurse licensure participates in Nursys®, you must request verification of your licensure through Nursys® (www.nursys.com), not the state(s). If your state(s) of licensure does not appear on the Nursys® list of licensure participatingboardsofnursing,youmustusetheCT-NURform (VerificationofLicensing Agency/Board) to verify your license to the Illinois Board of Nursing.

ED-NUR

Certification of Education

If you received your nursing education in the United States or one of its territories and areapplyingforlicensureunderexaminationorendorsement,youmustsubmitthisform. 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 sealaffixed.Directtheprogramtoreturntheformtoyouandsubmititwithyourapplication for licensure and/or examination.

TP-NUR Temporary Permit

This form provides a means of applying for licensure pending the processing of an endorsement/restorationapplication. Theentireformistobecompletedbytheapplicant. Failuretoproperlycomplete,signanddatethisformwillresultinadelayintheprocessing of your temporary endorsement or restoration permit.

Verification of

Employment/Experience

Fill in the top portion of this form. Then submit it to your employer to be completed by the Personnel Representative for Nursing Services. Instruct that person to fill out the remainder of the form and return it to you for enclosure with the rest of your application. The purpose of this form is to provide proof of your active engagement in nursing in another jurisdiction.

RS	This is one of the forms you must complete to restore your Illinois Registered Nurse
Restoration	license. The applicant is to complete the entire form and submit it with the other
	documentation as requested on page 7.

RegisteredNurse-Page11

LICENSURE METHODS AND DEFINITIONS

Following are definitions of the various methods used in issuing licenses for professionals in the State of Illinois. Some of these licensure methods may not be applicable to your profession. Refer to the enclosed instruction sheet to determine the specific licensure methods/requirements for your profession.

Licensure Methods	Definition
Examination	Applicant has applied or is required to take and pass all
	or a portion of an exam scheduled and/or given by the
	Department or a representative of the Department.
Endorsement of License	Original license issued in another state and that state's
	requirements were substantially equivalent to Illinois
	requirements at time license was issued.
Acceptance of Examination	Applicant has taken a National Exam, referred to by
	Illinois statute, in any state. Applicant may or may not be
	licensed in another state.
Restoration	Applicant has previously been licensed in State of Illinois
	and has allowed license to lapse long enough to require
	reapplication. Possible exam passage and/or committee
	review.
Grandfather/Waiver	Applicant will be licensed without regard to current
	requirements because statute allows this based on past
	qualification and practices (for a specified time only).
Non-examination	Applicant is licensed by meeting qualifications required
	by statute. There is no exam for these professions.
	These can be either businesses or individuals.

DPR-I-DEFINE D 7/06

IMPORTANT NOTICE

Elder and Child Abuse Reporting

"Pursuant to Public Act 91-0244, effective January 1, 2000, if you have reason to believe that an adult 60 years of age or older who resides in a domestic living situation who, because of dysfunction is unable to seek assistance for himself or herself has, within the previous 12 months been subject to abuse, neglect or financial exploitation, the mandated reporter shall, within 24 hours after developing such belief, report this suspicion to the Department on Aging. Reports should be made to DEPARTMENT ON AGING AT 1-800-252-8966."

_____________________________________

"Public Act 91-0244 also requires that if you have reasonable cause to believe a child known to you in your professional capacity may be an abused or neglected child you are required to report such possible neglect or abuse to the DEPARTMENT OF CHILDREN AND FAMILY

SERVICES AT 1-800-25abuse."

DPR-I-abuse 12/99

REFERENCE SHEET

ALL FEES ARE NONREFUNDABLE

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

if prevailing circumstances necessitate such action.

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

Profession Name		Profession		Licensure		Application
		Code		Method		Fee

RegisteredNurse	041			Examination(CTS)	$91.00
			Examination(NCSBN)		$200.00
RegisteredNurse	041		Endorsement of License		$50.00
				Temporary Permit	$25.00
RegIsteredNurse	041			Restoration	See Supporting Document RS
				TemporaryPermit	$25.00

CHART II - EXAMINATION CODES AND FEES

Since the application for examination is a dual process, you must:

Complete the Department's licensure/examination application by applying online at www.continentaltesting.net and pay the required administration fee as noted above; and

Register for the examination through the NCLEX Examination website at www.ncsbn.org/nclex.htm.

Once you have completed both processes and are determined eligible you will receive:

An Authorization to Test (ATT) that will contain the necessary information to schedule yourself for this examination. The ATT eligibility lasts for 90 days only. You must take the examination within those 90 days or reapply with new fees to CTS and Pearson Vue.

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

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

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

Licensure Methods Except Examination (US ONLY)

1-800-560-6420

TTY

1-866-325-4949

Please allow 6 weeks from mailing your application before making an inquiry concerning its status.

Examination Licensure Method Only

1-708-354-9911

SEE REVERSE SIDE FOR CHART IV - SCHOOL CODES

DPR-RN 8/13

Reference Sheet - Page 1 of 2

CHART IV - SCHOOL CODES

ILLINOIS NURSING EDUCATION PROGRAMS - PROGRAMS PREPARING REGISTERED NURSES

AURORA		GRAYSLAKE
49-581	Aurora University	49-490	College of Lake County
BELLEVILLE		HARRISBURG
49-455	Southwestern Illinois College	49-444	Southeastern Illinois College
BLOOMINGTON		INA
49-511	Ill Wesleyan Univ	49-441	Rend Lake College
BOURBONNAIS		JACKSONVILLE
49-550	Olivet Nazarene University	49-578	MacMurray College
CANTON		JOLIET
49-351	Graham Hospital	49-503	University of St. Francis
49-402	Spoon River College		College of Nursing and Allied Health
CARTERVILLE		49-499	Joliet Junior College
49-442	John A. Logan College	KANKAKEE
CENTRALIA		49-496	Kankakee Community College
49-486	Kaskaskia College	MACOMB
CHAMPAIGN		49-523	Western Illinois University
49-452	ParklandCollege	MALTA
CHICAGO		49-476	Kishwaukee College
49-582	Chicago State University	MATTOON
49-510	DePaul University	49-401	Lake Land College
49-488	Kennedy-King College	MOLINE
49-586	Loyola University	49-433	Black Hawk College
49-453	Malcolm X College	49-440	Trinity College of Nursing (ADN)
49-598	North Park University	NORMAL
49-454	Olive-Harvey College	49-434	Heartland Comm. College
49-477	Richard J. Daley College	49-556	Mennonite College of Nursing
49-400	Robert Morris College		at Illinois State University
49-516	Rush University	OAK PARK
49-530	Rush University Master's Entry	49-557	Concordia W. Suburban C of N
49-584	St. Xavier University	OGLESBY
49-416	TrumanCollege	49-458	Illinois Valley Comm College
49-514	University of Illinois	OLNEY
49-526	University of Illinois at Chicago--MSN	49-466	Ill Eastern Comm Colleges
CHICAGO HTS.		PALATINE
49-462	Prairie State College	49-456	Wm Rainey Harper College
CICERO		PALOSHEIGHTS
49-487	Morton College	49-580	Trinity Christian College
CRYSTAL LAKE		PALOS HILLS
49-410	McHenry County College	49-484	Morraine Valley Comm College
DANVILLE		PEORIA
49-504	Lakeview College of Nursing	49-502	St. Francis Md. Ctr. Coll. Nsg.
49-423	Danville Area Community College	49-549	Bradley University
DE KALB		49-497	Illinois Central College--East Peoria
49-559	Northern Illinois University	49-560	Methodist Medical Center College of
DECATUR			Nursing
49-558	Millikin University	QUINCY
49-432	RichlandComm.College	49-541	Blessing Riemer/Culver Stockton College
DESPLAINES		49-431	John Wood Comm. College
49-450	Oakton Community College	RIVERGROVE
DIXON		49-406	Triton College
49-451	Sauk Valley College	ROCKFORD
EDWARDSVILLE		49-505	Rockford College
49-513	Southern Illinois University	49-506	St. Anthony College of Nursing
ELGIN		49-457	Rock Valley College
49-492	ElginCommunityCollege	ROMEOVILLE
ELMHURST		49-583	Lewis University
49-591	ElmhurstCollege	SOUTHHOLLAND
FREEPORT		49-467	South Suburban College
49-470	HighlandCommunityCollege	SPRINGFIELD
GALESBURG		49-507	St. John's College
49-485	Carl Sandburg College	49-480	Lincoln Land Community Coll.
GLENELLYN		SUGARGROVE
49-495	College of DuPage	49-489	Waubonsee Comm College
GODFREY		ULLIN
49-483	Lewis & Clark Community College	49-443	Shawnee Community College

DPR-RN 8/13	Reference Sheet - Page 2 of 2

Illinois Department of Financial and Professional Regulation

Division of Professional Regulation

Application Checklist for Registered Nurses

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

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

FOUR-PAGE APPLICATION REVIEW		COMPLETED
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		SUBMITTED

Application Fee

Supporting Document CCA must be completed and submitted with each application. Your application will not be processed without completion of this form.

ED-NUR Form with seal and signature affixed; or

Nursing transcripts with seal affixed.

CGFNS or CES Report

CT-NUR Form (original and current state)

CT-NUR Form from states practicing within last 5 years

Verification requested from NURSYS (if applicable)

VE Form (if applicable)

Proof of Name Change (if applicable)

Criminal Background Check Requested

Proof of Fingerprint Submission

TP-NUR Form (if applicable)

Copies of Active Licenses (temporary permit only)

RS Form (restoration method only)

Current NCLEX exam passage (if applicable)

All supporting documents may not be required. Please refer to application instructions

for your specific method of licensure.

IL486-1971 (RN) 12/12

APPLICATIONFOR

LICENSUREAND/OREXAMINATION

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.

FOR OFFICIAL USE ONLY

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 different from that shown on your application, you must submit PROOF OF LEGAL NAME change - copy of mar- riage license, divorce decree, affidavit or court order.

Carefully follow all steps outlined on the INSTRUCTION SHEET. In addition, note the following:

A.Type or print legibly with black ink only.

B.FEESARENOTREFUNDABLE.

C.Disclosure of your U.S. social security number, if you have one, is mandatory, in accordance with 5 Illinois Compiled Statutes 100/ 10-65 to obtain a license. The social security number may be provided to the Illinois Department of Public Aid to identify persons who are more than 30 days delinquent in complying with a child support order, or to the Illinois Department of Revenue to identify persons who have failed to file a tax return, pay tax, penalty or interest shown in a filed return, or to pay any final assessment or tax penalty or interest, as required by any tax Act administered by the Illinois Department of Revenue, or to other entities for verification of identification.

PART I: Application Category Information

A.SEEREFERENCE SHEET, CHARTI,ORINSTRUCTIONSPRIORTOCOMPLETINGITEMS1THROUGH4

1. PROFESSION NAME	2. PROFESSIONCODE	3. LICENSURE METHOD	4. FEE
			$

B. CHECKBOXINDICATINGTHEAPPROPRIATEINFORMATIONREGARDINGYOURAPPLICATION

This is the first 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:

My application for this profession had previously been denied in Illinois. I am reapplying since I have fulfilled additional requirements.

I have previously made application for this profession in Illinois. However, I am now applying under new statutory language.

PART II: Applicant Identifying Information--You must notify the Department of Financial and Professional Regulation - Division of Professional Regulation and/or Continental Testing Service in writing, of any address changes after you file this application in order to receive any further information.

1. NAME

LAST

FIRST

MIDDLE

2. TITLE (e.g., M.D., D.D.S., etc.)

3. UNITEDSTATESSOCIALSECURITYNO.

PERMANENT MAILING ADDRESS STREET

CITYSTATE/COUNTRY

ZIP CODE

COUNTY

BUSINESS ADDRESS STREET

CITYSTATE/COUNTRY

ZIP CODE

COUNTY

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

7. MOTHER'SMAIDENNAME

8. PLACE OF BIRTH

CITY STATE/COUNTRY

9. DATE OF BIRTH

10.AGE

Female

Male

Month

Day

Year

11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED

12. PREFERREDe-MAIL

Work: ( __ __ __ ) __ __ __ __ __ __ __ __

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

ADDRESS(ES) [If available]

(Area Code)

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

Fax:

( __ __ __ ) __ __ __ __ __ __ __ __

(Area Code)

IL486-1019 03/06 (LT)

APPLICATIONFORLICENSUREAND/OREXAMINATION-Page1of4

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

PART III: Education Information

1. PRELIMINARY EDUCATION (Elementary and High School or G.E.D. Circle number of years completed)

1	2	3	4	5	6	7	8	9	10	11 12	Graduated			Received
1	2	3	4	5	6	7	8	9	10	11 12	High School?	Yes	No	OR G.E.D.?			Yes	No
											High School?	Yes	No	OR G.E.D.?			Yes	No

2. NAME OF LAST PRELIMINARY SCHOOL											3. LAST PRELIMINARY SCHOOL LOCATION				4. DATE OF GRADUATION
ATTENDED											(City and State)

																Month		Year

5. COLLEGE OR UNIVERSITY (Circle number of years completed)

1 2 3 4 5 6 7 8		Graduated?	Yes	No

	6. COLLEGE OR UNIVERSITY NAME	LOCATION		DATES OF ATTENDANCE		TYPE OF
	(Undergraduate and Graduate)	(City and State or Country)		FROM	TO	DEGREE EARNED
				FROM	TO

				Month/Year	Month/Year

7. SPECIALIZED TRAINING (Residency, Professional Training, Vocational Training, Practical or Clinical Training)

	LOCATION	DATES OF ATTENDANCE		Did You Complete
INSTITUTION NAME	(City and State or Country)	FROM	TO	Training?


		Month/Year	Month/Year
				Yes	No

				Yes	No

				Yes	No

				Yes	No

				Yes	No

NAME (Last, First, MI):SS#:Profession:

IL486-1019 03/06 (LT)

APPLICATIONFORLICENSUREAND/OREXAMINATION-Page2of4

PART IV:	Record of Licensure Information

If you have ever been licensed to practice the profession for which you are now making application, or held a related license, complete the information requested below. If you have ever held a temporary, trainee or apprenticeship license, or a permit, it must be listed here also. In addition, the INSTRUCTION SHEET enclosed with this Application package may instruct you tohaveCertification(s)ofLicensureinotherstate(s)preparedandsubmittedinsupportofyourapplication(contactotherstate(s) regarding possible fee). You must also list all other licenses held in Illinois, however, certification of licensure from Illinois is not required. Failure to disclose all licenses held may result in denial of your application or other appropriate action.

STATE	PROFESSION NAME	LICENSE NUMBER	DATE OF	LICENSESTATUS
STATE	PROFESSION NAME	LICENSE NUMBER	ISSUANCE	(Active, Lapsed, etc.)
			ISSUANCE	(Active, Lapsed, etc.)

State of Original Licensure

State of Current Licensure where you most recently have been practicing.

Other States of Licensure

(Ifadditionalspaceisneeded,attachaseparatesheet.)

PART V: Record of Examination

If you have ever taken a licensure examination in Illinois or any other state for the profession for which you are now making application,youmustcompletetheinformationrequestedbelow.EACHEXAMINATIONATTEMPTMUSTBE SHOWN.Failure to disclose an examination attempt may result in the denial of your application or other appropriate action.

NAME OF EXAMINATION

STATE

MONTH/YEAR

EXAM RESULTS

(Passed, Failed, Absent)

(Ifadditionalspaceisneeded,attachaseparatesheet.)

NAME (Last, First, MI):SS#:Profession:

IL486-1019 03/06 (LT)

APPLICATIONFORLICENSUREAND/OREXAMINATION-Page3of4

APPLICATIONFORLICENSUREAND/OREXAMINATION-Page4of4

PART VI: Personal History Information (This part must be completed by all applicants)	YES NO

1.Have you been convicted of any criminal offense in any state or in federal court (other than minor traffic violations)? If yes, attach a certified copy of the court records regarding your conviction, the nature of the offense and date of discharge, if applicable, as well as a statement from the probation or parole office.

2.Have you been convicted of a felony?

3.If yes, have you been issued a Certificate of Relief from Disabilities by the Prisoner Review Board? If yes, attach a copy of the certificate.

4.Have you had or do you now have any disease or condition that interferes with your ability to perform the essential functions of your profession, including any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease or condition; (2) alcohol or other substance abuse; (3) physical disease or condition, that presently interferes with your ability to practice your profession? If yes, attach a detailed statement, including an explanation whether or not you are currently under treatment.

5.Have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license or permit disciplined in any way by any licensing authority in Illinois or elsewhere? If yes, attach a detailed explanation.

6.Have you ever been discharged other than honorably from the armed service or from a city, county, state or federal position? If yes, attach a detailed explanation.

PART VII:	Examination Coding Information (This part is for examination applicants only)

Refer to the REFERENCE SHEET enclosed with this application package and complete the following:

a)CHART II - Select examination(s) you desire and enter Test Codes.

b)	CHARTIII-	Select the examination site you desire and enter Test Center Code:
c)	CHART IV -	Find your School of Graduation and enter school code:

d) Record the number of times you have taken this exam in Illinois or any other state:

PART VIII: Child Support and/or Student Loan Information (Every applicant is required by law to respond to the followingquestions)

1.In accordance with 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's Social Security number, and the licensee shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to contempt of court.

Are you more than 30 days delinquent in complying with a child support order?	Yes	No
(NOTE: If you are not subject to a child support order, answer "no.")

2.In accordance with 20 Illinois Compiled Statutes 2105/2105-(5), "The Department shall deny any license or renewal authorized by the Civil Administrative Code of Illinois to any person who has defaulted on an educational loan or scholarship provided by or guaranteed by the Illinois Student Assistance Commission or any governmental agency of this State; however, the Department may issue a license or renewal if the aforementioned persons have established a satisfactory repayment record as determined by the Illinois Student Assistance Commission or other appropriate governmental agency of this State." (Proof of a satisfactory repayment record must be submitted.)

Are you in default on an educational loan or scholarship provided/guaranteed by the Illinois
Student Assistance Commission or other governmental agency of this State?	Yes	No

PART IX: Certifying Statement

Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connection therewith, and to the best of my knowledge, they are true, correct, and complete.

Signature of Applicant

Date

I UNDERSTAND THAT FEES ARE NOT REFUNDABLE. My signature above authorizes the Department of Financial and Professional Regulation to reduce the amount of this check if the amount submitted is not correct. I understand this will be done only if the amount submitted is greater than the required fee hereunder, but in no event shall such reduction be made in an amount greater

than $50. IL486-1019 03/06 (LT)

NAME (Last, First, MI):SS#:Profession:

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

1.	NAME	LAST	FIRST	MIDDLE	3.	PROFESSIONAL LICENSE NUMBER (if any)
						__ __ __ - __ __ __ __ __ __

2.	ADDRESS	STREET,	CITY, STATE, ZIP CODE		4.	SOCIAL SECURITY NUMBER
						__ __ __ - __ __ - __ __ __ __

Pursuant to 20ILCS 2105-165(a), the Department requires the following professionals to disclose information regarding convictions pertaining to certain offenses. Please check applicable profession.

Acupuncturists

Advanced Practice Nurses

Athletic Trainers

Audiologists

Clinical Psychologists

Clinical Social Workers

Dental Hygienists

Dentists

Genetic Counselors

Licensed Clinical

ProfessionalCounselors

Licensed Practical Nurses

Licensed Social Workers Marriage and Family Therapists

Naprapaths

Nursing Home Administrators

OccupationalTherapists

Occupational Therapy Assistants

Optometrists

Orthotists

Pedorthists

Perfusionists

Pharmacists

Physical Therapists

Physical Therapy Assistants

Physicians, including Medical Doctors

(M.D.), Doctors of Osteopathic

Medicine (D.O.), and Chiropractic

Physicians (D.C.)

Physician Assistants

Podiatrists

ProfessionalCounselors

Prosthetists

RegisteredNurses

Registered Surgical Assistants

Registered Surgical Technologists

Respiratory Care Practitioners

Speech Pathologists

Any other license issued by the Department under the Acts listed in this Section and the Controlled Substances Act [740 ILCS 40], except for pharmacy technicians, issued to a person subject to the Code and this Part.

In order for your application to be evaluated, you must respond to each of the following questions:

1)	Are you currently charged with or have you been convicted of a criminal act that requires registration	Yes	No
	under the Sex Offender Registration Act? *

2)	Are you currently charged with or have you been convicted of a criminal battery against any patient in the
	course of patient care or treatment, including any offense based on sexual conduct or sexual penetration?

3)	Are you required, as part of a criminal sentence, to register under the Sex Offender Registration Act? *

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

If YES to any of the above, attach a certified copy of the court records regarding your conviction, the nature of the offense and date of discharge, if applicable, as well as a statement from the probation or parole office.

Certification Statement

Under penalties of perjury, I declare that I have examined this Form and all supporting documents and/or information submitted by me in connection therewith, and to the best of my knowledge, they are true, correct, and complete.

Signature of Applicant

Date

IL486-2034 02/13 (crimacts)

Page 1of 3

* DEFINITIONS

730 ILCS 150 et. seq:—Acts that require Sex Offender Registration:

(B)As used in this Article, “sex offense” means:

(1)A violation of any of the following Sections of the Criminal Code of 1961:

11-20.1 (child pornography),

11-20.3 (aggravated child pornography),

11-6 (indecent solicitation of a child),

11-9.1 (sexual exploitation of a child),

11-9.2 (custodial sexual misconduct),

11-9.5 (sexual misconduct with a person with a disability), 11-15.1 (soliciting for a juvenile prostitute),

11-18.1 (patronizing a juvenile prostitute),

11-17.1 (keeping a place of juvenile prostitution),

11-19.1 (juvenile pimping),

11-19.2 (exploitation of a child),

11-25 (grooming),

11-26 (traveling to meet a minor),

12-13 (criminal sexual assault),

12-14 (aggravated criminal sexual assault),

12-14.1 (predatory criminal sexual assault of a child), 12-15 (criminal sexual abuse),

12-16 (aggravated criminal sexual abuse),

12-33 (ritualized abuse of a child). An attempt to commit any of these offenses.

(1.5) A violation of any of the following Sections of the Criminal Code of 1961, when the victim is a person under 18 years of age, the defendant is not a parent of the victim, the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act, and the offense was committed on or after January 1, 1996:

10-1 (kidnapping),

10-2 (aggravated kidnapping),

10-3 (unlawful restraint),

10-3.1 (aggravated unlawful restraint).

(1.6) First degree murder under Section 9-1 of the Criminal Code of 1961, when the victim was a person under 18 years of age and the defendant was at least 17 years of age at the time of the commission of the offense, provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.

(1.7) (Blank).

(1.8) A violation or attempted violation of Section 11-11 (sexual relations within families) of the Criminal Code of 1961, and the offense was committed on or after June 1, 1997.

(1.9) Child abduction under paragraph (10) of subsection (b) of Section 105 of the Criminal Code of 1961 committed by luring or attempting to lure a child under the age of 16 into a motor vehicle, building, house trailer, or dwelling place without the consent of the parent or lawful custodian of the child for other than a lawful purpose and the offense was committed on or after January 1, 1998, provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.

(1.10) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed on or after July 1, 1999:

10-4 (forcible detention, if the victim is under 18 years of age), provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act,

11-6.5 (indecent solicitation of an adult),

11-15 (soliciting for a prostitute, if the victim is under 18 years of age), 11-16 (pandering, if the victim is under 18 years of age),

11-18 (patronizing a prostitute, if the victim is under 18 years of age), 11-19 (pimping, if the victim is under 18 years of age).

(1.11) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed on or after August 22, 2002:

11-9 (public indecency for a third or subsequent conviction).

(1.12) A violation or attempted violation of Section 5.1 of the Wrongs to Children Act (permitting sexual abuse) when the offense was committed on or after August 22, 2002.

(2)A violation of any former law of this State substantially equivalent to any offense listed in subsection (B) of this Section.

(C)A conviction for an offense of federal law, Uniform Code of Military Justice, or the law of another state or a foreign country that is substantially equivalent to any offense listed in subsections (B), (C), (E), and (E5) of this Section shall constitute a conviction for the purpose of this Article.

IL486-2034 02/13 (crimacts)

Page 2 of 3

* DEFINITIONS

A “forcible felony”, for the purposes of Section 2105-165 of the Code (section numbers are from the Criminal Code of 1961 [720 ILCS 5]) and 68 Illinois Administrative Code 1130.120 is one or more of the following offenses:

a)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)Trafficking 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);

aa)Aggravated Robbery (Section 18-5);

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 specified offenses.

IL486-2034 02/13 (crimacts)

Page 3 of 3

IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure under 225 ILCS 65/1 et.seq. of (Illinois Compiled Statutes). Disclosure of this information is VOLUNTARY. However, failure to comply may result in this form not being processed.

VERIFICATION BY LICENSING

AGENCY/BOARD

SUPPORTING DOCUMENT

CT-NUR

FOR EXAM USE ONLY

APPLICANT: Complete the applicant section of this form then forward this form to the state or territory in which you are requesting verification of your examination status, license or examination scores. Contact certifying jurisdiction for appropriate fee. Photocopying this form is permissible.

NAME

LAST

FIRST

MIDDLE

DATE OF BIRTH

3. SOCIAL SECURITY NUMBER

__ __ / __ __ / __ __ __ __

Month Day

Year

ADDRESS STREET, CITY, STATE, ZIP CODE

REFER TO REFERENCE SHEET. Record profession name and three

digit profession code for which you are making Illinois application.

Profession

Name

Profession Code

6. MAIDEN OR GIVEN SURNAME

7. APPLICANT TELEPHONE NUMBER (Daytime)

Area Code (

)

7a. RECORD PROFESSION NAME AS IT APPEARS ON YOUR LICENSE FROM THE JURISDICTION TO WHICH THIS FORM IS BEING FORWARDED.

(If applicable)

7b. LICENSE NUMBER (If applicable)

7c. ISSUANCE DATE OF LICENSE (If applicable)

I hereby authorize			to furnish to the Illinois Department of
	Name of Licensing Agency or Board
Financial and Professional Regulation or its designated testing service, the information requested below.
Signature		Date



	DO NOT RETURN COMPLETED FORM TO APPLICANT
LICENSING AGENCY:	Complete the remainder of this form. Use Part V on the reverse side of this form for any
	additional information relating to the examination status of the above-named applicant
	which has not been provided on this form (i.e. wrote the National State Board Test Pool
	Examination, etc.) Please record N/A in areas which are not applicable.

PART I. - VERIFICATION OF EXAMINATION STATUS

A. The applicant

has written the following examination

times.

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

Month

Day

Year

NAME OF EXAMINATION

DATE OF

RESULTS

DATE OF

RESULTS

EXAMINATION

Passed

Failed

EXAMINATION

Passed

Failed

National Council Licensure Examination for Registered Nurses (NCLEX-RN)

National Council Licensure Examination for Practical Nurses (NCLEX-PN)

B. Nursing Education Program Completed.

Name of Program

Location of Program

Year of Graduation

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 07/04 (NS)

EXAM CT-NUR

- Verification by Licensing Agency/Board - Page 1 of 2

PART II. - VERIFICATION OF LICENSURE

A. NAME OF PROFESSION AS IT APPEARS ON LICENSE

B. LICENSE NUMBER

C. ISSUANCE DATE OF LICENSE

D. EXPIRATION DATE OF LICENSE

E. LICENSURE METHOD

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)

F. CURRENT LICENSURE STATUS

Active

Lapsed

Inactive

Other (explain)

PART III. - VERIFICATION OF EXAMINATION SCORES

A. National

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

REGISTERED NURSE

LPN

MEDICAL

PSYCHIATRIC

OBSTETRIC

SURGICAL

NURSING OF

NCLEX/COMP.

RESULTS

NURSING

CHILDREN

EXAM

Standard Scores

Series/Form No.

B. State Constructed Examination

Registered Nurse

Licensed Practical Nurse

SUBJECT

SCORE

SUBJECT

SCORE

PART IV. - FORMAL ACTIONS
A. Is there now or has there ever been any formal action commenced against the applicant?	Yes	No

B.Have there ever been any formal sanctions imposed against the applicant as a matter of public record including but not limited to fine, reprimand, probation, censure, revocation, suspension,

surrender, restriction or limitation? (If yes, attach a certified copy of disciplinary action.)

Yes

PART V. - ADDITIONAL INFORMATION

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

	Print Name

	Title			Signature
S E A L

	Agency/Board Street Address			Date
			Area Code (	)
	City, State, ZIP Code		Telephone Number

	RETURN TO:	Continental Testing Service, Inc.
		P.O. Box 100
		LaGrange, Illinois 60525-0100

NAME (Last, First, MI):SS#:Profession:

___________________

IL486-0307 07/04 (NS)

EXAM CT-NUR

- Verification by Licensing Agency/Board - Page 2 of 2

CERTIFICATION OF EDUCATION

SUPPORTING DOCUMENT

ED-NUR

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

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.

6. MAIDEN OR GIVEN SURNAME

Profession Name

Profession Code

7. NAME OF INSTITUTION ATTENDED

8. DATE OF GRADUATION/COMPLETION

__ __ / __ __ / __ __ __ __

Month

Day

Year

I hereby authorize a school official of the institution named above to furnish to the Illinois Department of Financial and Professional Regulation or its designated testing service the information requested below.

DateSignature of Applicant

SCHOOL OFFICIAL:	Complete the bottom portion of this page and the reverse side, then return to the
	applicant.


A. NAME OF INSTITUTION	B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE

C.DEPARTMENT OF INSTITUTION

D.MAJOR AREA OF STUDY OF THE APPLICANT

E. DATES OF ATTENDANCE

					From __ __ / __ __ / __ __ __ __		To __ __ / __ __ / __ __ __ __
					Month Day	Year	Month Day	Year
F. Total academic years attended					G.TYPE OF DEGREE OR CERTIFICATE AWARDED (e.g., BA., MA.,
					Ph.D.)
OR		Years	Months	Days	Ph.D.)
OR		Years	Months	Days
Total calendar years attended
		Years	Months	Days
H. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS WERE MET					I. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED
__ __ / __ __ / __ __ __ __					__ __ / __ __ / __ __ __ __
Month Day	Year				Month Day	Year

J. IF EDUCATION PROGRAM WAS COMPLETED IN LESS THAN THE NORMALLY REQUIRED TIME, PLEASE EXPLAIN:

IL486-1031 07/04 (NS)

ED-NUR - Certification of Education - Page 1 of 2

K. NURSING SCHOOL PROGRAM CODE

NCSBN Number

SUBMISSION OF THIS FORM PRIOR TO PROGRAM COMPLETION WILL RESULT IN ITS RETURN TO THE PROGRAM FOR CORRECTION.

I certify that the educational information recorded herein is true and correct according to the official records of this institution.

Print Name of Dean or Director of Nursing	License Number	Signature of Dean or Director of Nursing

Title		Date

SCHOOL SEAL OR NOTARY SEAL
	NOTE: If the institution does not have a school seal, this form must be notarized.
	Subscribed and sworn before me this ______day of_________________, 20____.

	Date of Expiration	Signature of Notary Public

	RETURN THIS FORM TO APPLICANT

NAME (Last, First, MI):SS#:Profession:

___________________

IL486-1031 07/04 (NS)

ED-NUR - Certification of Education - Page 2 of 2

IMPORTANT NOTICE

CRIMINAL BACKGROUND CHECK INFORMATION

Individuals applying for licensure for professions that require fingerprints must submit to a criminal background check and provide evidence of fingerprint processing from the Illinois State Police (ISP), or a fingerprint vendor licensed by the Department. Fingerprints must be taken within 60 days from the date that the application is submitted to the Department or the Department’s testing vendor.

Certifying Statement of Fingerprint Submission Form (FP), or a receipt issued by a licensed fingerprint vendor must be submitted with the application and fee. The receipt shall be issued by the vendor at the time that fingerprints are obtained.

Applicants may contact a licensed fingerprint vendor to schedule an appointment for fingerprinting by going to https://www.idfpr.com/LicenseLookUp/fingerprintlist.asp . The ISP will transmit electronic results of fingerprint processing to the Department.

Out-of-State applicants who are unable to schedule an appointment for fingerprinting through a licensed fingerprint vendor must obtain one (1) Illinois State Police (ISP) fingerprint card for processing by the ISP. The ISP will transmit electronic results of fingerprint processing to the Department. To obtain a fingerprint card, please contact the Department at 1-800-560-6420 or send an email request on your profession page of the Department website at www.idfpr.com.The fingerprint card may be taken to a police department in another state to obtain classifiable prints. The fingerprint card and processing fee shall then be mailed to ISP as follows:

Illinois State Police

Bureau of Identification

260 North Chicago Street

Joliet, Illinois 60432-4075

For fingerprint processing fees, please contact ISP at http://www.isp.state.il.us/docs/5-727.pdf

or at the following email address: BOI_Customer_Support@isp.state.il.us

PRIVACY STATEMENT

I understand by submitting fingerprints to the Department of Financial and Professional Regulation, Division of Professional Regulation any criminal history information may be shared, and I authorize the release of any information that may exist regarding me from any agency, organization, institution, or entity having such information on file. I am aware and understand that my fingerprints may be retained and will be used to check the criminal history record information files of the Illinois State Police and/or the Federal Bureau of Investigation. I further understand that I have the right to challenge any information disseminated from these criminal justice agencies regarding me that may be inaccurate or incomplete pursuant to Title 28 Code of Federal Regulation 16.34 and Chapter 20 ILCS 2630/7 of the Criminal IdentificationAct.

IL486-2052 05/12

CERTIFYING STATEMENT OF FINGERPRINT SUBMISSION

SUPPORTING DOCUMENT

FP-NUR

APPLICANT: This form must be completed by out-of-state residents unable to utilize the livescan process for fingerprinting in the State of Illinois. Attach this certifying statement with the four-page Application for Licensure and/or Examination as proof of having submitted the required fingerprint cards to the proper authorities.

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.

	Registered Nurse	0 4 1

6. MAIDEN OR GIVEN SURNAME
	Licensed Practical Nurse	0 4 3

CERTIFYING STATEMENT

Under penalties of perjury, I declare that I, ____________________________________, have submitted

the required fingerprints pursuant to Section 5-30 of the Nursing and Advanced Practice Nursing Act (225 ILCS 65) and the Rules for the Administration of the Act (68 Ill. Adm. Code 1305) to the designated agent of the Illinois State Police for processing.

Date: ________________________________________

Signature: __________________________

IL486-1889ns 03/08 (NS)

Question	Answer
Form Name	Dpr Rn Form
Form Length	29 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	7 min 15 sec
Other names	ERES, ed nur illinois form, CGFNS, ed nur form

Dpr Rn Form – Fill Out and Use This PDF

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