This is the fi rst time I have made application for this
profession in Illinois.
I have previously made application for this profession in
Illinois. However, my previous application expired and I
am now reapplying.
Other:
4. PERMANENT MAILING ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY
5. BUSINESS ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY
PART I: Application Category Information
4. FEE
C. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION
3. UNITED STATES SOCIAL SECURITY NO.
6. MAIDEN, GIVEN SURNAME, OR ANY NAME(S) UNDER WHICH SUPPORTING
DOCUMENTS WILL BE SUBMITTED. (SEE INSTRUCTIONS #5 ABOVE)
The following materials are required to make Application for Licensure and/
or Examination in Illinois:
1. Four page APPLICATION FOR LICENSURE and /or EXAMINATION.
2. INSTRUCTION SHEET, which gives step by step application
instructions for your profession.
3. REFERENCE SHEET, which gives detailed coding information for
your profession.
4. SUPPORTING DOCUMENTS, forms, and/or any other documentation
you may be required to submit with your application.
5. If the name shown on your supporting documents is diff erent from
that shown on your application, you must submit PROOF OF LEGAL
NAME change - copy of marriage license, divorce decree, affi davit or
court order.
1. PROFESSION NAME
1. NAME LAST FIRST MIDDLE
8. PLACE OF BIRTH CITY STATE/COUNTRY
11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED
PART II: Applicant Identifying Information--You must notify the Department of Financial and Professional Regulation -
Division of Professional Regulation and/or Continental Testing Service in writing, of any address changes after you
fi le this application in order to receive any further information.
IL486-1019 4/22 (LT)
3. LICENSURE METHOD
2. PROFESSION CODE
My application for this profession had previously been denied
in Illinois. I am reapplying since I have fulfi lled additional
requirements.
I have previously made application for this profession in
Illinois. However, I am now applying under new statutory
language.
2. TITLE (e.g., M.D., D.D.S., etc.)
Day Year
9. DATE OF BIRTH
Month
$
B. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4
Carefully follow all steps outlined on the INSTRUCTION SHEET. In addition,
note the following:
A. Type or print legibly with black ink only.
B. FEES ARE NOT REFUNDABLE.
C. Disclosure of your U.S. social security number, if you have one, is mandatory,
in accordance with 5 Illinois Compiled Statutes 100/10-65 to obtain a license.
The social security number may be provided to the Illinois Department of
Public Aid to identify persons who are more than 30 days delinquent in
complying with a child support order, or to the Illinois Department of Revenue
to identify persons who have failed to fi le a tax return, pay tax, penalty or
interest shown in a fi led return, or to pay any fi nal assessment or tax penalty
or interest, as required by any tax Act administered by the Illinois Department
of Revenue, or to other entities for verifi cation of identifi cation.
10. AGE
Female
Male
Work: ( __ __ __ ) __ __ __
__
__ __ __ __ Home: ( __ __ __ ) __ __ __
__
__ __ __ __
(Area Code) (Area Code)
APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4
12.
Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov
7. MOTHER'S MAIDEN NAME
APPLICATION FOR
LICENSURE AND/OR EXAMINATION
IMPORTANT NOTICE: Completion of this form is
necessary for consideration for licensure under 225 of the
Illinois Compiled Statutes. Disclosure of this information
is VOLUNTARY. However, failure to comply may result
in this form not being processed.
Fax: ( __ __ __ ) __ __ __
__
__ __ __ __ Fax: ( __ __ __ ) __ __ __
__
__ __ __ __
(Area Code) (Area Code)
REQUIRED
E-MAIL ADDRESS
A. Check the box indicating the appropriate information regarding your application. Military Military Spouse Not Military Decline to Answer
Military service member is defi ned as. “Service member means any person who, at the time of application under this Section, is an active duty member of the United
States Armed Forces or any reserve component of the United States Armed Forces, the Coast Guard, or the National Guard of any state, commonwealth, or territory
of the United States or the District of Columbia or whose active duty service concluded within the preceding 2 years before application.” The following will be
considered proof of you or your spouse’s active military status: DD214, Letter of Service signed by Unit Commanding Offi cer, or Proof of Service document from the
Servicemember's electronic personnel portal. Proof for Spouses: Military Permanent Change of Station Orders with the spouse identifi ed by name; Offi cial
Notifi cation of Change of Assignment with your marriage license, a certifi ed DD1172 verifying marital status, or a letter signed by the commanding offi cer verifying
change of assignment and the name of the military spouse.