Dpr Rn Form PDF Details

Navigating the path to becoming a Registered Nurse (RN) in Illinois involves understanding the detailed requirements and procedures outlined in the DPR RN form. This comprehensive document serves as a guide through the application process, whether you are seeking licensure through examination, endorsement, or restoration. For those aiming to practice nursing with the highest standards of care, the form outlines the mandatory submission of all supporting documentation alongside the application and the required fee. This protocol is in alignment with the Illinois Nurse Practice Act, aimed at ensuring the safety and health of the public by regulating the competence and integrity of nursing professionals. The form provides thorough instructions for candidates educated within the U.S. and its territories as well as those educated abroad, addressing unique stipulations for each. Additionally, the form specifies the importance of criminal background checks, the protocol for submitting credentials in foreign languages, and details regarding fees and timelines for application processing. For RN licenses, expiration occurs on May 31st of every even-numbered year, necessitating timely renewals. Moreover, for international applicants, there are specific guidelines for credential evaluation and English proficiency verification. This document also mentions the unique position of graduates from unaccredited programs like Excelsior College, requiring additional review to ensure applicants meet Illinois' rigorous nursing standards.

QuestionAnswer
Form NameDpr Rn Form
Form Length29 pages
Fillable?No
Fillable fields0
Avg. time to fill out7 min 15 sec
Other namesERES, ed nur illinois form, CGFNS, ed nur form

Form Preview Example

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 -

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.

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.

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.

- 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).

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.

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

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.

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.

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

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.

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.

- 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)

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 passing score on the Inter-based test is 83.

TOEFLscorespreviouslyconsideredas"passing"scoreswillbeacceptedfor 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 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.

VE

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.

4.

PERMANENT MAILING ADDRESS STREET

CITYSTATE/COUNTRY

 

ZIP CODE

 

 

 

 

 

COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

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)

 

 

 

(Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Fax:

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

 

 

 

 

 

 

 

 

(Area Code)

 

 

 

(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

 

 

 

 

 

 

 

 

High School?

Yes

No

OR G.E.D.?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. NAME OF LAST PRELIMINARY SCHOOL

 

3. LAST PRELIMINARY SCHOOL LOCATION

 

4. DATE OF GRADUATION

ATTENDED

 

 

 

 

 

 

 

 

 

(City and State)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

1 2 3 4 5 6 7 8

Graduated?

Yes

No

 

 

 

 

 

 

 

 

 

 

6. COLLEGE OR UNIVERSITY NAME

LOCATION

 

DATES OF ATTENDANCE

TYPE OF

 

(Undergraduate and Graduate)

(City and State or Country)

 

FROM

TO

DEGREE EARNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

LOCATION

DATES OF ATTENDANCE

Did You Complete

INSTITUTION NAME

(City and State or Country)

FROM

TO

Training?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

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

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

 

 

 

 

 

 

form is necessary to accomplish the

 

HEALTH CARE WORKERS

 

 

requirements outlined in 225 of the Illinois

 

 

 

 

CHARGED WITH OR CONVICTED

 

CCA

Compiled Statutes. Disclosure of this

 

 

information is VOLUNTARY.

However,

 

OF CRIMINAL ACTS

 

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.

 

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.

 

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.

 

 

NCLEX/COMP.

 

 

 

RESULTS

 

 

 

 

 

 

 

NURSING

NURSING

 

NURSING

NURSING

 

CHILDREN

 

EXAM

 

 

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

No

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

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.

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

 

 

 

 

 

 

 

 

 

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

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.

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)