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 Nursing and Advanced Practice Nursing Act, "For the protection of life and the promotion of health, and the prevention of illness and communicable diseases, any person practicing or offering to practice professional and practical nursing in Illinois shall submit evidence that he or she is qualified to practice, and shall be licensed as hereinafter provided." A copy of the Illinois Nursing and Advanced Practice Nursing 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. Table of Contents
Page

Applying for Licensure ............................................................................ 2 General Instructions ............................................................................. 2 Examination .......................................................................................... 2

General Examination Instructions ........................................................ 2 Practicing Pending Licensure by Examination .................................... 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 ................................................................................ 5 Educated Inside U.S. or one of its Territories...................................... 6 Educated Outside U.S. or one of its Territories ................................... 6 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 04/06

Packet updated 04/23/07

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 on how to apply for the examination on-line and pay the test fee by credit card. 2. Read these instructions, then read the Filing Instructions related to the method 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. All individuals applying for initial licensure as a registered 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: The Criminal Background Check Requirement does not apply to those applicants making application for registered nurse examination/ 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, who is fluent in both English and the language of the documents(s). The translator shall certify to the above requirements as well as to the accuracy of the translation. 5. For information concerning the completion of any of the enclosed forms, refer to the Forms Completion Guide on pages 10 and 11. You may photocopy any 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 Instructions 1. Read the above General Instructions before proceeding. All documents and forms required for licensure by examination must be submitted to: Continental Testing Services Inc. P.O. Box 100 LaGrange, Illinois 60525-0100 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.
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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 completed in three years, the application shall be denied, the fee forfeited, and the applicant must reapply and meet the requirements in effect at the time of application. An applicant who has taken and failed to pass the examination within 3 years after filing the application must submit proof of successful completion of a Department-authorized nursing education program or recompletion of an approved registered nursing program or licensed practical nursing program as appropriate, prior to reapplication. NOTE: Excelsior College a/k/a/ the University of the State of New York Regents External Degree Program 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 Nursing and Advanced Practical Nursing Act. Therefore, it is considered to be a correspondence course which is identified by the Act as not meeting the requirements for licensure. Practicing Pending Licensure by Examination The Department no longer issues work permits pending licensure by examination. First time candidates making application for examination will receive notification from Continental Testing Services, Inc., advising them of the receipt and approval of their application for licensure. At that time, you may practice in accordance with Section 5-15 (i) of the Illinois Nursing and Advanced Practice Nursing Act, which states, "the Act does not prohibit the practice of professional nursing by one who has applied in writing to the Department in form and substance satisfactory to the Department for a license as a registered nurse, and has complied with all the provisions under Section 10-30 except the passing of an examination to be eligible to receive such license until: the decision of the Department that the applicant has failed to pass the next available examination authorized by the Department, or failed, without an approved excuse, to take the next available examination authorized by the Department, or the withdrawal of the application, not to exceed 3 months. An applicant practicing registered professional nursing under this Section who passes the examination may continue to practice until such time as he or she receives his or her license to practice or until the Department notifies him or her that the license has been denied. NO APPLICANT FOR LICENSURE PRACTICING UNDER THE PROVISIONS OF THIS PARAGRAPH SHALL PRACTICE PROFESSIONAL NURSING EXCEPT UNDER THE DIRECT SUPERVISION OF A REGISTERED PROFESSIONAL NURSE LICENSED UNDER THIS ACT."

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

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 General Examination Instructions on page 2 now, if you have not already done so): a. Application for Licensure and/or Examination (four-page);
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EXAMINATION (cont'd)
b. CT-NUR Form (Verification of Licensing Agency/Board)--Submit a 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. 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;

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

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

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. Application for Licensure and/or Examination (four page); b. CT-NUR Form (Verification of Licensing Agency/Board)--Submit a 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. 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. 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) Credentials Evaluation Service (CES). The required report is the Healthcare Profession & Science Course-by-Course Report. The Division will download the credentials evaluation report from CGFNS' Web site when it becomes available. You may contact CGFNS Credentials Evaluation Service as follows: Credentials Evaluation Service CGFNS/ICHP 3600 Market Street, Suite 400 Philadelphia, PA 19104-2651 Telephone #215/349-8767 Web site: http://www.cgfns.org Additionally, 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 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. d. Fee--See page 2, General Examination Instructions, paragraph 2.
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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 endorsement must be submitted as a packet to: Illinois Department of Financial and Professional Regulation ATTN: Division of Professional Regulation P.O. Box 7007 Springfield, IL 62791 2. Fee payment must be in the form of a check or money order made payable to Department of Financial and Professional Regulation (see Reference Sheet, Chart I). NOTE: Excelsior College a/k/a/ the University of the State of New York Regents External Degree Program 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 Nursing and Advanced Practical Nursing 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 applicant 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. Temporary Permit
- Important Notice Applicants educated outside the U.S. or its Territories must have an acceptable credentials evaluation report from a Department-approved credentials evaluation service on file with the Department indicating their nursing education is comparable to an entry-level registered professional nursing education program in the United States prior to being deemed eligible for a temporary permit.

In accordance with Section 10-30(f) of the Illinois Nursing and Advanced Practice Nursing 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 Instructions on Page 2 and the General Endorsement Instructions above now, if you have not yet done so): a. Application for Licensure and/or Examination (four page); 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 jurisdiction(s) of the United States. Current licensure in at least one other jurisdiction of the United States is required by the Illinois Nursing and Advanced Practice Nursing Act;
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ENDORSEMENT (cont'd)
Temporary Permit (cont'd) d. Fee--Combine the endorsement fee and the temporary permit fee into one check or money order. (See page 5, General Endorsement Instructions, paragraph 2, for additional information.)

Educated Inside U.S. or one of its Territories

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. Application for Licensure and/or Examination (four page). You need not resubmit this form if you previously applied for a temporary endorsement permit; b. 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. 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. Current registration in another state is required by the Illinois Nursing and Advanced Practice Nursing Act. You must direct the licensing agency/board to return the completed form to you to be submitted with your application. c. ED-NUR Form (Certificate of Education); d. Fee--See General Endorsement Instructions, page 5, paragraph 2.

Educated Outside U.S. or its Territories

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. 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 registration in another state is required by the Illinois Nursing and Advanced Practice 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.

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ENDORSEMENT (cont'd)
Educated Outside U.S. or its Territories (cont'd) You must direct the licensing agency/board to return the completed form to to you to be submitted with your application. c. Request the following proof of education to be prepared for and made available to the Department: 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) Credentials Evaluation Service (CES). The required report is the Healthcare Profession & Science Course-by-Course Report. The Division will download the credentials evaluation report from CGFNS' Web site when it becomes available. You may contact CGFNS Credentials Evaluation Service as follows: Credentials Evaluation Service CGFNS/ICHP 3600 Market Street, Suite 400 Philadelphia, PA 19104-2651 Telephone #215/349-8767 Web site: http://www.cgfns.org Additionally, 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 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. d. Fee - See page 5, General Endorsement Instructions, paragraph 2.

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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 Instructions Do the following if you wish to apply for the restoration of your license because it 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, Illinois 62791 Fee payment must be in the form of a check or money order made payable to the Department of Financial and Professional Regulation. (See the 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. RS Form (Restoration) If this form was not included in the application packet, you must obtain one by contacting the Department of Financial and Professional Regulation at 217-782-0458; 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. 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. 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. e. 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 may be required to complete an Illinois approved current Nursing Practice Update Course prior to the restoration of their license. Proof of successful completion of an approved current Nursing Practice Update Course may be submitted with your application.
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~IMPORTANT NOTICE~ 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.

RESTORATION (cont'd)
Temporary Permit In accordance with Section 20-10(b) of the Illinois Nursing and Advanced Practice Nursing Act, you may apply for a temporary permit. The permit is valid for six (6) months from the date of issuance, or re-issuance of a permanent license by restoration or notification that 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);

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 Nursing and Advanced Practice Nursing 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.

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FORMS COMPLETION GUIDE

This guide will help you complete the forms needed to apply for licensure. For specific information regarding the forms which you will be required to submit, refer to the filing instructions relative to the method of licensure under which you are applying. Application for Licensure and/or Examination Provide all applicable information requested on all four pages of the application. 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.

CT-NUR Verification of Licensure

This document must be completed by the licensing jurisdiction(s) of original licensure, current state of licensure and any jurisdiction in which you have actively practiced within the last 5 years. Verification of licensure for a previously held LPN license within the last 5 years will only be required if you were not subsequently licensed in the same jurisdiction as an RN. Complete applicant section of form; then send form to each state or territory in which you have ever held registered or practical nurse licensure. Completion of CT-NUR form is not necessary if license is held in Illinois. Direct the licensing agency/board to return the completed form to you and submit it with your application for licensure and/or examination.
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FORMS COMPLETION GUIDE (cont'd)

ED-NUR Certification of Education

If you received your nursing education in the United States or one of its territories and are applying for licensure under examination or endorsement, you must submit this form. Complete the applicant section of this form, then send the form to the educational institution at which you completed your registered nurse education program. The form must be signed by the dean or director of your nursing education program with school seal affixed. Direct the program to return the form to you and submit it with your application for licensure and/or examination.

TP-NUR Temporary Permit

This form provides a means of applying for licensure pending the processing of an endorsement/restoration application. The entire form is to be completed by the applicant. Failure to properly complete, sign and date this form will result in a delay in the processing of your temporary endorsement or restoration permit.

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 Restoration

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

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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. Original license issued in another state and that state's requirements were substantially equivalent to Illinois requirements at time license was issued. Applicant has taken a National Exam, referred to by Illinois statute, in any state. Applicant may or may not be licensed in another state. 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. Applicant will be licensed without regard to current requirements because statute allows this based on past qualification and practices (for a specified time only). Applicant is licensed by meeting qualifications required by statute. There is no exam for these professions. These can be either businesses or individuals.

Endorsement of License

Acceptance of Examination

Restoration

Grandfather/Waiver

Non-examination

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 and fees if prevailing circumstances necessitate such action. CHART I - PROFESSION NAME, PROFESSION CODE, LICENSURE METHOD & FEE PROFESSION CODE 041 LICENSURE METHOD Examination (CTS) Examination (NCSBN) Endorsement of License Temporary Permit Restoration Temporary Permit APPLICATION FEE $79.00 $200.00 $50.00 $25.00 See Supporting Document RS $25.00

PROFESSION NAME Registered Nurse

Registered Nurse

041

RegIstered Nurse

041

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 of $79.00; and " Register for the examination through the Web, mail, or telephone as described in the attached NCLEX Examination Candidate Bulletin. The fee will be $200. Once you have completed both processes and are determined eligible you will receive: " An approval letter from CTS; and " 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 a new fee. 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 217/782-8556 Telecommunicative Device for the Deaf (TDD) 217/524-6735 Please allow 3 weeks from mailing your application before making an inquiry concerning its status. Examination Licensure Method Only 708/354-9911

SEE REVERSE SIDE FOR CHART IV - SCHOOL CODES

DPR-RN 12/06

Reference Sheet - Page 1 of 2

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

DPR-RN 12/06

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 Part I. Part II. Part III. Part IV. Part V. Part VI. Part VII. Part VIII. Part IX. Application Category Information Applicant Identifying Information Education Information Record of Licensure Information Record of Examination Personal History Information Examination Coding Information (if applicable) Child Support and/or Student Loan Information Certifying Statement--Signed and Dated

COMPLETED

SUPPORTING DOCUMENTS Application Fee 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) Refresher Course (restoration method only) if applicable

SUBMITTED

All supporting documents may not be required. Please refer to application instructions for your specific method of licensure.
IL486-1970 (RN) 04/06

FOR OFFICIAL USE ONLY

APPLICATION FOR LICENSURE AND/OR EXAMINATION

IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure under 225 of the Illinois Compiled Statutes. Disclosure of this information is VOLUNTARY. However, failure to comply may result in this form not being processed.

The following materials are required to make Application for Licensure and/or Examination in Illinois: 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 marriage license, divorce decree, affidavit or court order. PART I: Application Category Information 1.

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 100/1065 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.

A. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4 3. LICENSURE METHOD 2. PROFESSION CODE 1. PROFESSION NAME

4. FEE

$
B. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION

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: PART II:

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.

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.
LAST FIRST MIDDLE 2. TITLE (e.g., M.D., D.D.S., etc.) 3. UNITED STATES SOCIAL SECURITY NO.

1. NAME

4. PERMANENT MAILING ADDRESS

STREET

CITY

STATE/COUNTRY

ZIP CODE

COUNTY

5. BUSINESS ADDRESS

STREET

CITY

STATE/COUNTRY

ZIP CODE

COUNTY

6. MAIDEN, GIVEN SURNAME, OR ANY NAME(S) UNDER WHICH SUPPORTING DOCUMENTS WILL BE SUBMITTED. (SEE INSTRUCTIONS #5 ABOVE) 8. PLACE OF BIRTH CITY STATE/COUNTRY 9. DATE OF BIRTH Month 11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED Day

7. MOTHER'S MAIDEN NAME

10. AGE Year

Female Male
12. PREFERRED e-MAIL ADDRESS(ES) [If available]

Work: ( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code)

Home: ( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code)

Fax:

( __ __ __ ) __ __ __ __ __ __ __
(Area Code)

__

Fax:

( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code) APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4

IL486-1019 03/06 (LT)

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

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

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
2. NAME OF LAST PRELIMINARY SCHOOL ATTENDED

Graduated High School?

Yes

No

Received OR G.E.D.?

Yes

No

3. LAST PRELIMINARY SCHOOL LOCATION (City and State)

4. DATE OF GRADUATION Month Year

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

1 2 3 4 5 6 7 8
6. COLLEGE OR UNIVERSITY NAME (Undergraduate and Graduate)

Graduated?
LOCATION (City and State or Country)

Yes

No
DATES OF ATTENDANCE FROM TO Month/Year Month/Year TYPE OF DEGREE EARNED

7. SPECIALIZED TRAINING (Residency, Professional Training, Vocational Training, Practical or Clinical Training) DATES OF ATTENDANCE LOCATION INSTITUTION NAME (City and State or Country) TO FROM Month/Year Month/Year

Did You Complete Training?

Yes

No

Yes

No

Yes

No

Yes

No

Yes
IL486-1019 03/06 (LT)

No

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

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

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 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). 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 State of Original Licensure PROFESSION NAME LICENSE NUMBER DATE OF ISSUANCE LICENSE STATUS (Active, Lapsed, etc.)

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

(If additional space is needed, attach a separate sheet.) 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, you must complete the information requested below. EACH EXAMINATION ATTEMPT MUST BE SHOWN. Failure to disclose an examination attempt may result in the denial of your application or other appropriate action.
NAME OF EXAMINATION STATE MONTH/YEAR EXAM RESULTS (Passed, Failed, Absent)

(If additional space is needed, attach a separate sheet.)

IL486-1019 03/06 (LT) APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 3 of 4

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

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

YES

NO

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. Select the examination site you desire and enter Test Center Code: Find your School of Graduation and enter school code:

b) CHART III c) CHART IV -

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 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? (NOTE: If you are not subject to a child support order, answer "no.") Yes 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) APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 4 of 4

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.

SUPPORTING DOCUMENT

VERIFICATION BY LICENSING AGENCY/BOARD

CT-NUR

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 Day Year 3. SOCIAL SECURITY NUMBER

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

Profession Code

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
Name of Licensing Agency or Board

to furnish to the Illinois Department of

Financial and Professional Regulation or its designated testing service, the information requested below. Signature Date RETURN COMPLETED FORM TO APPLICANT 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. has written the following examination times.
Month NAME OF EXAMINATION DATE OF EXAMINATION RESULTS Passed Failed Day Year RESULTS Passed Failed

LICENSING AGENCY:

PART I. - VERIFICATION OF EXAMINATION STATUS

A. The applicant

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

DATE OF EXAMINATION

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?
IL486-0307 04/06 (NS)

Yes

No

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

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

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 National Council Licensure Examination State Constructed Other (Name)
F. CURRENT LICENSURE STATUS

Endorsement of License (State) Acceptance of Examination Results Administered in Another State Waiver/Grandfather Other (Describe)

Active Inactive
PART III. - VERIFICATION OF EXAMINATION SCORES

Lapsed Other (explain)

A. National N.S.B.T.P.E. RESULTS

Standard Scores Series/Form No. REGISTERED NURSE MEDICAL NURSING PSYCHIATRIC NURSING OBSTETRIC NURSING SURGICAL NURSING NURSING OF CHILDREN NCLEX/COMP. EXAM LPN NCLEX/COMP. EXAM

B. State Constructed Examination

SUBJECT

Registered Nurse
SCORE SUBJECT

Licensed Practical Nurse

SCORE

PART IV. - FORMAL ACTIONS

A. Is there now or has there ever been any formal action commenced against the applicant? 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.)
PART V. - ADDITIONAL INFORMATION

Yes

No

Yes

No

I certify that the information contained herein is true and correct according to the official records of the State.
Print Name Title Signature Date Area Code ( City, State, ZIP Code ) Telephone Number

SEAL
Agency/Board Street Address

Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT. Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.
IL486-0307 04/06 (NS) 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.

SUPPORTING DOCUMENT

CERTIFICATION OF EDUCATION

ED-NUR
3. SOCIAL SECURITY NUMBER

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

__ __ / __ __ / __ __ __ __
4. ADDRESS STREET CITY STATE ZIP CODE Month Day Year 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 7. NAME OF INSTITUTION ATTENDED 8. DATE OF GRADUATION/COMPLETION Profession Code

__ __ / __ __ / __ __ __ __
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.

Date

Signature of Applicant

SCHOOL OFFICIAL:

Complete the bottom portion of this page and the reverse side, then return to the applicant.
B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE

A. NAME OF INSTITUTION

C. DEPARTMENT OF INSTITUTION

D. MAJOR AREA OF STUDY OF THE APPLICANT

E. DATES OF ATTENDANCE

From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __
F.

Total academic years attended OR Total calendar years attended

Years Years

Months Months

Days Days

Month Day Year Month Day Year G.TYPE OF DEGREE OR CERTIFICATE AWARDED (e.g., BA., MA., Ph.D.)

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

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

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

IL486-1031 07/04 (NS)

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

IMPORTANT NOTICE: Completion of this form is necessary to accomplish the requirements outlined in 225 of the Illinois Compiled Statutes. Disclosure of this information is VOLUNTARY. However, failure to comply may result in this form not being processed.

SUPPORTING DOCUMENT

VERIFICATION OF EMPLOYMENT / EXPERIENCE

VE

APPLICANT: Complete the application section of this form, then forward it to your employer. Upon receipt of the completed form from the employer, include it with your Application for Licensure/Examination. You are authorized to photocopy this form as necessary.
1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH 3. SOCIAL SECURITY NUMBER

__ __ / __ __ / __ __ __ __
Month 4. ADDRESS STREET, CITY, STATE, ZIP CODE Day Year

__ __ __ - __ __ - __ __ __ __

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. JOB TITLE OR POSITION APPLICANT HELD

8. DATES OF EMPLOYMENT

9. SUPERVISOR NAME Month Day Year

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

Month Day Year

EMPLOYER:

Complete the remainder of this form. Return the completed form to the applicant in a sealed envelope.
B. BUSINESS / INSTITUTION NAME

PART I - EMPLOYMENT INFORMATION A. EMPLOYER NAME

C. EMPLOYER REGISTRATION/ LICENSE NUMBER F. BUSINESS REGISTRATION/ LICENSE NUMBER (If Applicable)

D. STATE OF EMPLOYER REGISTRATION/LICENSE G. STATE OF BUSINESS REGISTRATION/LICENSE

E. BUSINESS ADDRESS

STREET

CITY

STATE

ZIP CODE

H. BUSINESS TELEPHONE NUMBER

Area Code (___ ___ ___) ___ ___ ___ _ ___ ___ ___ ___
C. DATES OF EMPLOYMENT

PART II - APPLICANT EMPLOYMENT INFORMATION A. NUMBER OF HOURS WORKED PER WEEK B. TYPE OF EMPLOYMENT

[ ]Full-time
D. RECORD APPLICANT'S POSITION TITLE(S)

[ ]Part-time

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

Month Day Year Month Day Year

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

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

Signature

Date IL486-1348 04/06 (L&T)

Title

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.

SUPPORTING DOCUMENT

TEMPORARY PERMIT

TP-NUR
3. SOCIAL SECURITY NUMBER

APPLICANT: This form must be completed in its entirety and accompanied by the four (4) page application jacket.
1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH

__ __ / __ __ / __ __ __ __
4. ADDRESS STREET, CITY, STATE, ZIP CODE 5. Month Day Year 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. Nursing Education Program Completed.

Name of Program Location of Program Year of Graduation

8. Licensure examination taken in your state of original licensure which was the basis for your initial licensure:
NAME OF EXAMINATION DATE OF EXAMINATION RESULTS Passed Failed DATE OF EXAMINATION RESULTS Passed Failed

National Council Licensure Examination for Registered Nurses (NCLEX-RN) National Council Licensure Examination for Practical Nurses (NCLEX-PN) Other:

9. List all states where you hold active current licenses for the profession for which you are now making application:

10. Which one of the states noted above is the state where you have most recently been practicing? 11. Have you been convicted of any crime under the laws of any jurisdiction of the United States: (a) which is a felony; or (b) which is a misdemeanor directly related to the practice of the profession within the last five (5) years? Yes No If so, submit certified copies of all court records pertaining to said conviction.

12. Have you had a license or permit related to the practice of nursing revoked, suspended, or placed on probation by another jurisdiction within the last five (5) years? Yes No If so, have appropriate board of nursing complete CT-NUR form and attach copies of disciplinary action. I certify the information and documents contained in this application are true and correct to the best of my knowledge. I understand should any of the information or documents contained herein be proven false, it may result in the denial of my Temporary Permit request and/or permanent endorsement/restoration application or other appropriate disciplinary action.

Signature IL486-1577 12/00 (NS)

Date

IMPORTANT NOTICE
CRIMINAL BACKGROUND CHECK REQUIREMENT
All individuals applying for initial licensure as a registered nurse or licensed practical 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. Applicant must contact one of the livescan fingerprint vendors approved by the Illinois State Police and the Department of Financial and Professional Regulation, Division of Professional Regulation, to schedule an appointment--see attached list. (Fingerprinting processing fees are established by the respective vendor and the Illinois State Police.) You must complete and take the enclosed vendor fingerprint form to your vendor.
A receipt substantiating proof of fingerprinting or the Department's Certifying Statement Fingerprint Submission form (FP-NUR) must be submitted to the Department or the Department's testing vendor along with the application for endorsement/examination or restoration. Refer to application instructions for details regarding application submission.

Graduates from Illinois nursing education programs may contact a livescan-fingerprinting vendor, approved by the Illinois State Police and the Department of Financial and Professional Regulation, Division of Professional Regulation, to schedule an appointment for fingerprinting. Each applicant will be provided a written receipt once they have been fingerprinted. This receipt must be submitted to the Department's testing vendor along with the examination application and fee in order for the applicant to be scheduled for the examination. Applicants unable to schedule an appointment at a livescan facility may submit a fingerprint card in lieu of livescan. (See "Out-ofState applicants" below.) Fingerprints must be taken within 60 days prior to submission of the application for licensure. Out-of-State applicants who are unable to schedule an appointment at a livescan facility are required to submit a fingerprint card for the State Police and FBI. To facilitate this process we have enclosed one fingerprint and the Certifying Statement Fingerprint Submission Form (FP-NUR). The card may be taken to a local police authority in any state to obtain classifiable prints. The card and processing fee may then be submitted to one of the vendors indicated on the next page. (Fees are established by the respective vendor and the Illinois State Police.) NOTE: If you are downloading an application from our Web site, you must contact the Department at the following address to obtain a fingerprint card. Department of Financial and Professional Regulation ATTN: Division of Professional Regulation 320 West Washington Street, 3rd Floor Springfield, IL 62786 Tele: 217-782-8556

IL486-1889ns 08/05 (NS)

Page 1 of 2

PRACTICE PENDING LICENSURE Examination Applicants First-time examination applicants must submit their original receipt from an Illinois State Police approved livescan fingerprinting vendor. Provided all other requirements for examination have been met, this receipt will allow them to practice in a license pending status pursuant to Section 5-15 (g, i) of the Nursing and Advanced Practice Nursing Act. A permanent license will not be issued until the applicant meets all requirements and the Department has received the security clearance. Endorsement Applicants Prior to the issuance of a temporary permit, the applicant must meet all applicable requirements and the Department must be in receipt of proof of fingerprinting. A Certifying Statement of Fingerprint Submission form (FP-NUR) is enclosed with your application. The temporary permit is valid for a period of six (6) months. A permanent license will not be issued until the applicant meets all requirements and the security clearance has been received by the Department. Restoration Applicants In addition to meeting the requirements necessary to restore a license, restoration applicants must submit receipt of proof of fingerprinting to the Department along with their application, fee and other supporting documents. A Certifying Statement of Fingerprint Submission form (FP-NUR) is enclosed with your application. If you have questions regarding the criminal background check requirement, you may call (217) 782-8556.

IL486-1889ns 08/05 (NS)

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.

SUPPORTING DOCUMENT

CERTIFYING STATEMENT OF FINGERPRINT SUBMISSION

FP-NUR

APPLICANT: This form must be completed by out-of-state residents unable to utilize the live scan 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

__ __ / __ __ / __ __ __ __
4. ADDRESS STREET, CITY, STATE, ZIP CODE 5. Month Day Year REFER TO REFERENCE SHEET. Record profession name and three digit profession code for which you are making Illinois application.

6.

MAIDEN OR GIVEN SURNAME

"Registered Nurse "Licensed Practical Nurse

041 043

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 08/04 (NS)

Livescan Fingerprint Vendors

Certified by the Illinois State Police Approved by the Department of Financial and Professional Regulation
Information regarding fees may be obtained from the respective vendor.

Accurate Biometrics/Art's Investigations ......................................................... 866/361-9944

Chicago, IL

Andy Frain Services, Inc. ................................................................................ 630/820-3820, Ext. 13

Aurora, IL

Anthonys Mobile Fingerprinting .................................................................... 312/474-6394

Chicago, IL

Argus Services, Inc. ......................................................................................... 312/922-6766

Chicago, IL

Background Resources, Inc. ........................................................................... 630/873-2270

Warrenville, IL

Big River Investigations ................................................................................... 217/228-9114

Quincy, IL

DeKalb Police Department ............................................................................. 815/748-8400

DeKalb, IL

Digby's Detective Security Agency, Inc. .......................................................... 312/326-1100, Ext. 1045

Chicago, IL

Fact Finders Group, Inc. ................................................................................. 708/283-4200

Park Forest, IL

Firm ................................................................................................................. 217/753-1190

Springfield, IL

Identix Identification Services ......................................................................... 800/377-2080

Springfield, IL

Security Training Solutions ............................................................................. 618/257-9106

OFallon, IL

Trace Identity Services, Inc. ............................................................................ 708/754-2900

Chicago Heights, IL

I-Livescan 04/07