INSTRUCTION SHEET

REGISTERED NURSE
lExamination
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
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 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

General Examination Instructions ................................................... 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 07/09 Packet updated 1/10/11
 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.
If you are licensed in another U.S. jurisdiction based on passage of the
national licensing examination, you are not an "examination" applicant.
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 and/or restoration 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 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, 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.

Registered Nurse - Page 2

 EXAMINATION (cont'd)

General Examination 3. Conditions of Application--Applicants have three years from the date of
Instructions (cont'd) 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, 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 Pursuant to 60-10(d)(e) of the Illinois Nurse Practice Act, an applicant may
Supervision 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 If you received your education in the United States or one of its territories, you
one of its Territories 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):
- IMPORTANT NOTICE - a. Application for Licensure and/or Examination (four-page);
b. CT-NUR Form (Verification of Licensing Agency/Board)--Submit a verifica-
The National Council of State Boards of
Nursing (NCSBN) handles verification of tion of licensure from the state of original licensure, current state of licensure,
licensure for many state boards of nursing who and any jurisdiction in which you have actively practiced within the last 5 years.
licensure participate in Nursys®. Please visit Verification of licensure for an LPN license held in another jurisdiction within
Nursys.com (www.nursys.com) or https:// the last 5 years will only be required if you were not subsequently licensed in
www.nursys.com/NLV/ the same jurisdiction as an RN.
LicenseVerificationJurisdictions.aspx to
view a complete list. You must direct the appropriate licensing agency(s)/board(s) to return the
If the state(s) where you have been licensed as completed form directly to you to be submitted with your application.
a nurse licensure participates in Nursys®, you c. ED-NUR Form (Certificate of Education)--Form must be signed by the Dean
must request verification of your licensure
or Director of your nursing education program with school seal affixed,
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does indicating graduation from a professional nursing education program approved
not appear on the Nursys® list of licensure by the Department or have been granted a certificate of completion of pre-
participating boards of nursing, you must use licensure requirements from another U.S. jurisdiction;
the CT-NUR form (Verification of Licensing
Agency/Board) to verify your license to the d. Fee--See page 2, General Examination Instructions, paragraph 2.
Illinois Board of Nursing.

Registered Nurse - Page 3

 EXAMINATION (cont'd)
Educated Outside the U.S. In order to be considered for licensure, applicants who received their education
or one of its Territories 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);

- IMPORTANT NOTICE - 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
The National Council of State Boards of any jurisdiction in which you have actively practiced within the last 5 years.
Nursing (NCSBN) handles verification of
licensure for many state boards of nursing who Verification of licensure for an LPN license held in another jurisdiction within
licensure participate in Nursys®. Please visit the last 5 years will only be required if you were not subsequently licensed in the
Nursys.com (www.nursys.com) or https:// same jurisdiction as an RN;
www.nursys.com/NLV/
LicenseVerificationJurisdictions.aspx to You must direct the appropriate licensing agency(s)/board(s) to return the
view a complete list. completed form directly to you to be submitted with your application.
If the state(s) where you have been licensed as
a nurse licensure participates in Nursys®, you c. Submit the following proof of education:
must request verification of your licensure
through Nursys® (www.nursys.com), not 1. A credentials evaluation report of your foreign nursing education from a
the state(s). If your state(s) of licensure does Department approved credentialing service. One such service is the
not appear on the Nursys® list of licensure Commission on Graduates of Foreign Nursing Schools (CGFNS) Creden-
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing tials Evaluation Service (CES). The required report is the Healthcare
Agency/Board) to verify your license to the Profession & Science Course-by-Course Report. The Division will
Illinois Board of Nursing. 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, the Educational Records Evaluation Service (ERES) has been
approved 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 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
- NOTE - Web site: http://www.eres.com
Proof of licensure in your Further, if your first language is not English, you shall be required to submit
country of certification of passage of the Test of English as a Foreign Language
education shall be (TOEFL). The minimum passing score on the paper-based test is 560. The
required as a part of the minimum passing score on the computer-based test is 220. The minimum
passing score on the internet-based test is 83.
credentialing process.

Registered Nurse - Page 4

 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 TOEFL scores previously considered as "passing" scores will be accepted
one of its Territories (cont'd) for a period of two years from the date of passage.
d. 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):
l CGFNS Certificate
l VisaScreen Program Certificate
e. 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 1. Read the Applying for Licensure, General Instructions on page 2 before
Instruction 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, 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 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.

Registered Nurse - Page 5

 ENDORSEMENT (cont'd)

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
- Important Notice -
that the Department intends to deny licensure, whichever comes first. It will be your
Applicants educated outside the responsibility to complete the endorsement licensure process prior to the expiration
U.S. or its Territories must have of the temporary permit. In order to receive the permit, submit the following forms and
an acceptable credentials documentation (read the General Instructions on Page 2 and the General Endorse-
evaluation report from a
ment Instructions above now, if you have not yet done so):
Department-approved
credentials evaluation service a. Application for Licensure and/or Examination (four page);
on file with the Department
indicating their nursing b. TP-NUR Form (Temporary Permit);
education is comparable to an c. Photostatic copies of all current active Registered/Licensed Practical Nurse
entry-level registered licenses and/or temporary permits/licenses held by you in any other jurisdiction(s)
professional nursing education
of the United States. Current licensure in at least one other jurisdiction of the
program in the United States
prior to being deemed eligible
United States is required by the Illinois Nursing and Advanced Practice Nursing
for a temporary permit. Act;
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.)
e. Proof of fingerprint submission in the form of a copy of the fingerprint receipt (for
Illinois graduates or Illinois residents), or a completed FP-NUR form for out-of-
state and foreign-educated applicants.

Educated Inside U.S. or In order to be considered for licensure, applicants who were educated in the United
one of its Territories 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;
- IMPORTANT NOTICE -
b. CT-NUR Form (Verification of Licensing Agency/Board--Submit verification
CERTIFICATION OF LICENSURE of licensure from the state of original licensure, current state of licensure and any
The National Council of State Boards of jurisdiction in which you have actively practiced within the last 5 years.
Nursing (NCSBN) handles verification of Verification of licensure for an LPN license held in another jurisdiction within the
licensure for many state boards of nursing who
licensure participate in Nursys®. Please visit last 5 years will only be required if you were not subsequently licensed in the same
Nursys.com (www.nursys.com) or https:// jurisdiction as an RN. Current registration in another state is required by the
www.nursys.com/NLV/ Illinois Nurse Practice Act. You must direct the licensing agency/board to return
LicenseVerificationJurisdictions.aspx to
view a complete list. the completed form to you to be submitted with your application.
If the state(s) where you have been licensed as c. ED-NUR Form (Certificate of Education) indicating graduation from a profes-
a nurse licensure participates in Nursys®, you sional nursing education program approved by the Department; or the granting of
must request verification of your licensure
through Nursys® (www.nursys.com), not a certificate of completion of pre-licensure requirements from another U.S.
the state(s). If your state(s) of licensure does jurisdiction. The ED form must be signed by the director of the nursing education
not appear on the Nursys® list of licensure program with the school seal affixed.
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing d. Fee--See General Endorsement Instructions, page 5, paragraph 2.
Agency/Board) to verify your license to the
Illinois Board of Nursing.

Registered Nurse - Page 6

 ENDORSEMENT (cont'd)

Educated Outside U.S. or In order to be considered for licensure, applicants who were educated outside the
its Territories 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;
- IMPORTANT NOTICE - b. CT-NUR Form (Verification of Licensing Agency/Board)--Submit verifica-
tion of licensure from the state of original licensure, current state of licensure
CERTIFICATION OF LICENSURE
and any jurisdiction in which you have actively practiced within the last 5
The National Council of State Boards of
Nursing (NCSBN) handles verification of
years. Current registration in another state is required by the Illinois Nursing
licensure for many state boards of nursing who and Advanced Practice Nursing Act. Verification of licensure for an LPN
licensure participate in Nursys®. Please visit license held in another jurisdiction within the last 5 years will only be required
Nursys.com (www.nursys.com) or https://
www.nursys.com/NLV/
if you were not subsequently licensed in the same jurisdiction as an RN.
LicenseVerificationJurisdictions.aspx to You must direct the licensing agency/board to return the completed form to
view a complete list.
you to be submitted with your application.
If the state(s) where you have been licensed as
a nurse licensure participates in Nursys®, you c. Request the following proof of education to be prepared for and make
must request verification of your licensure available to the Department:
through Nursys® (www.nursys.com), not
the state(s). If your state(s) of licensure does 1. A credentials evaluation report of your foreign nursing education from
not appear on the Nursys® list of licensure a Department approved credentialing service. The credentials evaluation
participating boards of nursing, you must use
the CT-NUR form (Verification of Licensing report must reflect proof of licensure in the country of education. One
Agency/Board) to verify your license to the such service is the Commission on Graduates of Foreign Nursing Schools
Illinois Board of Nursing. (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, the Educational Records Evaluation service (ERES) has been
- NOTE - approved by the Division as a nursing educational credentialing agency. The
Proof of licensure in your required report to request is the Nursing Evaluation and Course by Course
Report. The report will be downloaded from ERES when available.
country of
education shall be You may contact ERES as follows:
required as a part of the Educational Records Evaluation Service, Inc.
credentialing process. 601 University Avenue, Suite 127
Sacramento, CA 95825
Telephone # 916/921-0790
Email: edu@eres.com
Web site: http://www.eres.com

Registered Nurse - Page 7

 ENDORSEMENT (cont'd)

Educated Outside U.S. or Further, if your first language is not English, you shall be required to submit
its Territories (cont'd) 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.
TOEFL scores previously considered as "passing" scores will be accepted
for a period of two years from the date of passage.

d. 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):
l CGFNS Certificate
l VisaScreen Program Certificate

e. 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
Instructions 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;

Registered Nurse - Page 8

 RESTORATION (cont'd)

General Restoration c. CT-NUR Form (Verification of Licensing Agency/Board)--Submit verifica-

Instructions (cont'd) 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
~IMPORTANT NOTICE~ within the last 5 years will only be required if you were not subsequently
These Restoration
licensed in the same jurisdiction as an RN.You must direct the licensing
Instructions apply only to those agency/board to return the completed form to you to be submitted with your
registered nurses whose application.
licenses have been on inactive d. VE Form (Verification of Employment/Experience)--This form must be
status, or in non-renewed completed by the Personnel Representative for Nursing Services of your
status, for five or more years. place of employment and returned to the Department of Financial and
If your license has been Professional Regulation, Division of Professional Regulation in a sealed
inactive, or in non-renewed envelope.
status, for less than five
e. DD214--If restoring after active military service, submit a copy of this form.
years, you should contact the
Department of Financial and NOTE: If unable to provide proof of fitness to practice nursing via submission
Professional Regulation at of a VE form substantiating active engagement in nursing practice in
217/782-0458 for detailed another U.S. jurisdiction within the last five (5) years, persons making
instructions on how to application for restoration of license shall be required to successfully
restore it to active status. 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 In accordance with Section 60-25(b)(e) of the Illinois Nurse Practice 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 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.

Registered Nurse - Page 9

 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 Provide all applicable information requested on all four pages of the application.
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.

Registered Nurse - Page 10

 FORMS COMPLETION GUIDE (cont'd)

CT-NUR This document must be completed by the licensing jurisdiction(s) of original

Verification of Licensure 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.
Copies of licenses are not
Complete applicant section of form; then send form to each state or territory in
acceptable in lieu of an official
which you have ever held registered or practical nurse licensure. Completion of
verification of licensure. 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.
Important: The National Council of State Boards of Nursing (NCSBN) handles
verification 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.aspx to view a com-
plete 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.

ED-NUR If you received your nursing education in the United States or one of its territories
Certification of Education 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 This form provides a means of applying for licensure pending the processing of
Temporary Permit 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.

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

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

Registered Nurse - Page 11

 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 Licensure Application

Profession Name Code Method Fee

Registered Nurse 041 Examination (CTS) $91.00

Examination (NCSBN) $200.00

Registered Nurse 041 Endorsement of License $50.00

Temporary Permit $25.00

RegIstered Nurse 041 Restoration See Supporting Document RS

Temporary Permit $25.00

CHART II - EXAMINATION CODES AND FEES

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

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

o Register for the examination through the Web, mail, or telephone as described in the attached NCLEX Examination
Candidate Bulletin.

Once you have completed both processes and are determined eligible you will receive:
o An approval letter from CTS; and
o 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) Examination Licensure Method Only
217/524-6735 708/354-9911
Please allow 3 weeks from mailing your application before
making an inquiry concerning its status.

SEE REVERSE SIDE FOR CHART IV - SCHOOL CODES

DPR-RN 08/10 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 MALTA
CHAMPAIGN 49-476 Kishwaukee College
49-452 Parkland College MATTOON
CHICAGO 49-401 Lake Land College
49-582 Chicago State University MOLINE
49-510 DePaul University 49-433 Black Hawk College
49-488 Kennedy-King College 49-440 Trinity College of Nursing (ADN)
49-586 Loyola University NORMAL
49-453 Malcolm X College 49-434 Heartland Comm. College
49-598 North Park University 49-556 Mennonite College of Nursing
49-454 Olive-Harvey College at Illinois State University
49-477 Richard J. Daley College OAK PARK
49-400 Robert Morris College 49-557 Concordia W. Suburban C of N
49-516 Rush University OGLESBY
49-530 Rush University Master's Entry 49-458 Illinois Valley Comm College
49-584 St. Xavier University OLNEY
49-416 Truman College 49-466 Ill Eastern Comm Colleges
49-514 University of Illinois PALATINE
49-526 University of Illinois at Chicago--MSN 49-456 Wm Rainey Harper College
CHICAGO HTS. PALOS HEIGHTS
49-462 Prairie State College 49-580 Trinity Christian College
CICERO PALOS HILLS
49-487 Morton College 49-484 Morraine Valley Comm College
CRYSTAL LAKE PEORIA
49-410 McHenry County College 49-502 St. Francis Md. Ctr. Coll. Nsg.
DANVILLE 49-549 Bradley University
49-504 Lakeview College of Nursing 49-497 Illinois Central College--East Peoria
49-423 Danville Area Community College 49-560 Methodist Medical Center College of
DE KALB Nursing
49-559 Northern Illinois University QUINCY
DECATUR 49-541 Blessing Riemer/Culver Stockton College
49-558 Millikin University 49-431 John Wood Comm. College
49-432 Richland Comm. College RIVER GROVE
DES PLAINES 49-406 Triton College
49-450 Oakton Community College ROCKFORD
DIXON 49-505 Rockford College
49-451 Sauk Valley College 49-506 St. Anthony College of Nursing
EDWARDSVILLE 49-457 Rock Valley College
49-513 Southern Illinois University ROMEOVILLE
ELGIN 49-583 Lewis University
49-492 Elgin Community College SOUTH HOLLAND
ELMHURST 49-467 South Suburban College
49-591 Elmhurst College SPRINGFIELD
FREEPORT 49-507 St. John's College
49-470 Highland Community College 49-480 Lincoln Land Community Coll.
GALESBURG SUGAR GROVE
49-485 Carl Sandburg College 49-489 Waubonsee Comm College
GLEN ELLYN ULLIN
49-495 College of DuPage 49-443 Shawnee Community College
GODFREY
49-483 Lewis & Clark Community College

DPR-RN 08/10 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
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) 02/08
 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 Carefully follow all steps outlined on the INSTRUCTION SHEET. In
Licensure and/or Examination in Illinois: addition, note the following:
1. Four page APPLICATION FOR LICENSURE AND/OR A. Type or print legibly with black ink only.
EXAMINATION. B. FEES ARE NOT REFUNDABLE.
2. INSTRUCTION SHEET, which gives step by step C. Disclosure of your U.S. social security number, if you have one, is
application instructions for your profession. mandatory, in accordance with 5 Illinois Compiled Statutes 100/
3. REFERENCE SHEET, which gives detailed coding 10-65 to obtain a license. The social security number may be
information for your profession. provided to the Illinois Department of Public Aid to identify persons
4. SUPPORTING DOCUMENTS, forms, and/or any other who are more than 30 days delinquent in complying with a child
documentation you may be required to submit with your support order, or to the Illinois Department of Revenue to identify
application. persons who have failed to file a tax return, pay tax, penalty or
5. If the name shown on your supporting documents is interest shown in a filed return, or to pay any final assessment or
different from that shown on your application, you must tax penalty or interest, as required by any tax Act administered by
submit PROOF OF LEGAL NAME change - copy of mar- the Illinois Department of Revenue, or to other entities for verification
riage license, divorce decree, affidavit or court order. of identification.
PART I: Application Category Information
A. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4
1. PROFESSION NAME 2. PROFESSION CODE 3. LICENSURE METHOD 4. FEE
$
B. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION
This is the first time I have made application for this My application for this profession had previously been
profession in Illinois. denied in Illinois. I am reapplying since I have fulfilled
I have previously made application for this profession in additional requirements.
Illinois. However, my previous application expired and I am I have previously made application for this profession in
now reapplying. Illinois. However, I am now applying under new statutory
Other: 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. UNITED STATES SOCIAL SECURITY NO.

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 7. MOTHER'S MAIDEN NAME
DOCUMENTS WILL BE SUBMITTED. (SEE INSTRUCTIONS #5 ABOVE)

8. PLACE OF BIRTH CITY STATE/COUNTRY 9. DATE OF BIRTH 10.AGE

Female
Month Day Year Male
11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED 12. PREFERRED e-MAIL
ADDRESS(ES) [If available]
Work: ( __ __ __ ) __ __ __ __ __ __ __ __ Home: ( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code) (Area Code)
__
Fax: ( __ __ __ ) __ __ __ __ __ __ __ Fax: ( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code) (Area Code)
IL486-1019 03/06 (LT) APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4
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)
Graduated Received
1 2 3 4 5 6 7 8 9 10 11 12
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

IL486-1019 03/06 (LT) 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.
DATE OF LICENSE STATUS
STATE PROFESSION NAME LICENSE NUMBER ISSUANCE (Active, Lapsed, etc.)
State of Original Licensure

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) 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) CHART III - 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
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 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 $50.03/06 (LT)
IL486-1019 APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 4 of 4
 IMPORTANT NOTICE: Completion of this form SUPPORTING DOCUMENT
is necessary for consideration for licensure
under 225 ILCS 65/1 et.seq. of (Illinois VERIFICATION BY LICENSING
Compiled Statutes). Disclosure of this
information is VOLUNTARY. However, failure AGENCY/BOARD CT-NUR
to comply may result in this form not being
processed. 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 7b. LICENSE NUMBER 7c. ISSUANCE DATE OF LICENSE
FROM THE JURISDICTION TO WHICH THIS FORM IS BEING (If applicable) (If applicable)
FORWARDED.
(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

DATE OF RESULTS DATE OF RESULTS

NAME OF EXAMINATION 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
 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 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
REGISTERED NURSE LPN
N.S.B.T.P.E.
MEDICAL PSYCHIATRIC OBSTETRIC SURGICAL NURSING OF NCLEX/COMP. NCLEX/COMP.
RESULTS EXAM
NURSING NURSING NURSING NURSING CHILDREN EXAM
Standard Scores
Series/Form No.

B. State Constructed Examination Registered Nurse Licensed Practical Nurse

SUBJECT SCORE SUBJECT SCORE

PART IV. - FORMAL ACTIONS

A. Is there now or has there ever been any formal action commenced against the applicant? Yes No

B. Have there ever been any formal sanctions imposed against the applicant as a matter of public
record including but not limited to fine, reprimand, probation, censure, revocation, suspension,
surrender, restriction or limitation? (If yes, attach a certified copy of disciplinary action.) Yes 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
SEAL
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
IL486-0307 07/04 (NS) Exam CT-NUR - Verification by Licensing Agency/Board - Page 2 of 2
 IMPORTANT NOTICE: Completion of this SUPPORTING DOCUMENT
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
CERTIFICATION OF EDUCATION ED-NUR
processed.

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.

Date Signature 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. G.TYPE OF DEGREE OR CERTIFICATE AWARDED (e.g., BA., MA.,
Total academic years attended 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

 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

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.

u Graduates from Illinois nursing education programs and/or applicants residing in Illinois 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-of-State applicants" below.) Fingerprints must be taken within 60
days prior to submission of the application for licensure.

u 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).

u Fingerprint Card Process--For Out-of-State Applicants:

l Utilize a fingerprint card obtained from this Department/Division;
l Take it to a local police authority in any state to obtain classifiable prints;
l Contact an approved livescan vendor and make arrangements for them to process your
fingerprint card. Not all approved livescan vendors process the fingerprint card. Two such
vendors that do process the fingerprint card are Accurate Biometrics/Art's Investigations
or Identix. Send the fingerprint card directly to the approved livescan vendor.
l The fingerprint vendor will advise you of the processing fee.
l DO NOT send the card directly to the Illinois State Police or Federal Bureau of
Investigation (regardless of what is indicated on the card itself).
If you follow these instructions, the results of your criminal background check will be electronically
forwarded to this Department/Division when available. Failure to follow these instructions may
result in a delay in the processing of your application for licensure.

IL486-1889ns 03/08 (NS) Page 1 of 2

 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
Telephone: 217/782-8556

Practice Under Supervision

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 Nurse Practice Act. A permanent license will
not be issued until the applicant meets all requirements and the Department has received the security clearance.

Registered Nurse
Pursuant to Section 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.

Practical Nurse
Pursuant to Section 55-10(d)(e) of the Illinois Nurse Practice Act, an applicant may practice as a license-pending
practical 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 an Illinois licensed registered
professional nurse, advanced practice nurse, or physician. In no instance shall any such applicant practice or be
employed in any management capacity.

Practice Pending Licensure

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 03/08 (NS) Page 2 of 2
 SUPPORTING DOCUMENT
IMPORTANT NOTICE: Completion of this form is
necessary for consideration for licensure under
225 ILCS 65/1 et.seq. of (Illinois Compiled CERTIFYING STATEMENT OF
Statutes). Disclosure of this information is
VOLUNTARY. However, failure to comply may
result in this form not being processed.
FINGERPRINT SUBMISSION 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.

oRegistered Nurse 041

6. MAIDEN OR GIVEN SURNAME
oLicensed Practical Nurse 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 03/08 (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.

A Fingerprinting U S Photo ................................................................................................... 312/782-8144

Chicago, IL .............................................................................................. www.fingerprintingchicago.com

Accurate Biometrics ............................................................................................................. 866/361-9944

Chicago, IL .................................................................................................. www.accuratebiometrics.com

AGB Investigative Services, Inc. ........................................................................................... 773/445-4300

Chicago, IL ...................................................................................................... www.agbinvestigative.com

American Heritage Protective Services................................................................................ 708/388-7900

Alsip, IL ................................................................................................................... www.apservices.com

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

Aurora, IL ................................................................................................................... www.andyfrain.com

Anthony’s Mobile Fingerprinting, Inc. ................................................................................... 312/474-6394

Chicago, IL ................................................................................................... www.thefingerprintman.com

AP Private Detective Agency, Ltd. ........................................................................................ 708/922-3500

Hazel Crest, IL .......................................................................................... apprivatedetective@yahoo.com

Argus Services, Inc. .............................................................................................................. 312/377-9441

Chicago, IL ....................................................................................................... rkurz@argus_services.com

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

Warrenville, IL .......................................................................................... www.backgroundresources.com

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

Pittsfield, IL ........................................................................................... www.bigriversinvestigations.com

Biometric Impressions .......................................................................................................... 630/715-2760

Elmhurst, IL ............................................................................................. www.biometricimpressions.com

Browder’s Maximum Security Services, Inc. ........................................................................ 312/225-7900

Chicago, IL ............................................................................................................ maxsec@sbcglobal.net

Bushue Human Resources, Inc. ............................................................................................ 217/342-3042

Effingham, IL .............................................................................................................. www.bushuehr.com

CLS Background Investigations ............................................................................................ 815/836-0236

Homer Glen, IL ................................................................................................................ www.cls-ent.com

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

DeKalb, IL .............................................................................................................. www.cityofdekalb.com

Digby's Detective and Security Agency, Inc. ......................................................... 312/326-1100, Ext. 1045
Chicago, IL ........................................................................................................... www.digbysecurity.com

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

Matteson, IL .................................................................................................... www.factfindersgroup.com

I-Livescan 1/10/11 Livescan p. 1

 Livescan Fingerprint Vendors (cont’d)
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.

Futures in Rehab Management, Inc. (FIRM) .......................................................................... 217/753-1190

Springfield, IL ............................................................................................................... www.verifyinc.com

InfoTrack .............................................................................................................................. 847/444-1177

Deerfield, IL ............................................................................................................ www.infotrackinc.com

Integrated Biometric Technology ......................................................................................... 800-377-2080

Springfield, IL ........................................................................................................ www.ibtfingerprint.com

Kevin W. McClain Inv., LTD .................................................................................................. 618/532-1152

Central City, IL ......................................................................................... www.mcclaininvestigations.com

Kellerman Investigations ...................................................................................................... 618/288-6662

Glen Carbon, IL .................................................................................... www.kellermaninvestigations.com

Meador Investigations .......................................................................................................... 217/732-1585

Lincoln, IL ........................................................................................................................ www.pi-pro.com

Metro Enforcement ............................................................................................................... 815/964-9900

Rockford, IL .................................................................................................. www.metroenforcement.com

Midwest Professional Investigations ..................................................................................... 217/224-0757

Quincy, IL ........................................................................................................... www.mpinv@adams.net

Official Fingerprint Provider ................................................................................................. 312/942-1200

Chicago, IL ....................................................................................................................... www.official1.us

Per Mar Security ................................................................................................................... 563/326-2511

Davenport, IA ..................................................................................................... www.permarsecurity.com

Rich Wooten & Associates .................................................................................................... 773/651-3826

Chicago, IL ................................................................................................................ rawooten@msn.com

Rockford Detective Agency, Inc. ........................................................................................... 815/282-2822

Loves Park, IL .......................................................................................................... rockforddetective.com

Securitas Security Services USA .......................................................................................... 618/257-2815

O’Fallon, IL..............................................................................................................www.securitasinc.com

The Security Professionals, Inc. ........................................................................................... 773/581-8181

Chicago, IL ............................................................................................................... www.secprosinc.com

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

Chicago Heights, IL .............................................................................................. www.traceidentitysi.com

United Security Services, Inc. ............................................................................................... 312/922-8558

Chicago, IL .............................................................................................................. www.usesecurity.com

USA Fingerprint Service LLC ................................................................................................ 708/478-6157

Mokena, IL ............................................................................................... www.usafingerprintservice.com

I-Livescan 1/10/11 Livescan p. 2