Form Il486 1899 – Fill Out and Use This PDF

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

LICENSURE AND/OR EXAMINATION APPLICATION

FOR GRADUATES OF ILLINOIS NURSING PROGRAMS

The following materials are required for graduates of Illinois nurse programs to make application for examination in Illinois:

1. Two page LICENSURE AND/OR EXAMINATION APPLICATION FOR GRADUATES OF ILLINOIS NURSING PROGRAMS.

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 docu- mentation 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 marriage 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.FEES ARE NOT REFUNDABLE.

C.Disclosure of your U.S. social security number, if you have one, is mandatory, in accordance with 5 Illinois Compiled Statutes 100/10-65. 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.

1. PROFESSION NAME

2. PROFESSION CODE

___ ___ ___

3. LICENSURE METHOD

EXAMINATION

4. FEE

$

1. NAME

LAST

FIRST

MIDDLE

2. UNITED STATES SOCIAL SECURITY NO.

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. In addition, you are instructed to have Certification(s) of Licensure in other state(s) prepared and submitted in support of your application (contact other state(s) regarding possible fee). Failure to disclose all licenses held may result in denial of your application or other appropriate action.

	STATE	PROFESSION NAME	LICENSE NUMBER	DATE OF	LICENSE STATUS
				ISSUANCE	(Active, Lapsed, etc.)
	State of Original Licensure
	Other States of Licensure and/or Related
	Licenses

PART V: Record of Examination - Record any nurse examination(s) you have taken in Illinois or another state. All attempts must be recorded. (Use separate sheet of paper if necessary.)

	NAME OF EXAMINATION		MONTH/YEAR	EXAM RESULTS
				(Passed, Failed, Absent)
	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 VIII: Child Support and/or Student Loan Information (Every applicant is required by law to respond to the

PART VII: Child Support Information (This part must be completed by all applicants) following questions)

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 VIII: Certifying Statement

Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connec- tion 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.

NAME (Last, First, MI):

SS#:

_____________________

Profession:

___________________