INSTRUCTION SHEET

DENTAL SPECIALIST

NON - 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.

BEFORE COMPLETING THE APPLICATION, read each of the 4 steps below in the order that they are listed, then
follow the directions as they apply to you. This will aid you in accurately completing your application and eliminate any
delay in processing. THE APPLICATION WHICH YOU SUBMIT IS VALID FOR THREE (3) YEARS FROM
DATE OF RECEIPT.
Step 1. Use the REFERENCE SHEET (CHART I) to select the appropriate Profession Name, 3 digit Profession Code,
Licensure Method and Fee, and record that information in PART I (page one) of the Application for Licensure
and/or Examination.
Step 2. Proceed with PART II (page one) and complete all applicable information requested on all 4 pages of the
Application for Licensure and/or Examination.
NOTE: a) If you are a full Diplomate of the American Specialty Board in the specialty for which you are applying,
make application by Licensure Method NON-Examination (I), verifying passing scores for both the
written portion and the clinical portion.
b) Indicate both Pre-Dental and Dental Education in PART III, number 6, on the Application for
Licensure and/or Examination.
c) Indicate Specialty Training or Residency in PART III, number 7, on the Application for Licensure
and/or Examination.
Step 3. The remainder of this form contains specific instructions for each Licensure Method. Locate the instructions for
the Licensure Method you recorded in PART I (page one) of the Application for Licensure and/or Examination
and follow those instructions only.
NOTE: a) An applicant for licensure as a Dental Specialist must be currently licensed as a general dentist in
Illinois.
b) All documents in a foreign language that are required to be submitted with an application or for any
other purpose in connection with licensure must be accompanied by an original, notarized translation
that has been performed by a person, other than the applicant, who is fluent in both English and the
language of the document(s). The translator shall certify to the above requirements as well as to the
accuracy of the translation.
Step 4. If needed, a telephone number for assistance in completing the Application Package is provided on the REFERENCE
SHEET.

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov.
DPR-DN-SP Instructions Revised 12/23 Packet updated 1/25/24
 NON - 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.

1. Supporting Document TN-DEN must be completed, with school seal affixed, showing successful completion of
a course of study as described in paragraphs a, b, or c below. If policy prohibits the institution from forwarding
the completed form directly to you, you must direct the institution to return the completed form directly to the
address indicated in #4 below.

a. Endodontics, Orthodontics and Dentofacial Orthopedics, Pediatric Dentistry, Periodontics, Prosthodontics, or

Oral and Maxillofacial Radiology--TN-DEN must show completion of a course of study not less than two
(2) academic years in a program approved by the Department of Financial and Professional Regulation in
the dental specialty applicant proposes to practice. The TN-DEN form must be completed by the Director/
Administrator of the Specialty or Residency program.

b. Oral and Maxillofacial Surgery--TN-DEN must show the applicant has successfully completed a four (4)
year (48-month) period of training in Oral and Maxillofacial Surgery in a school and/or hospital approved
by the Department. A minimum of 30 months shall be in clinical oral and maxillofacial surgery. Preceptor
training programs will not be recognized in satisfaction of any part of the 4-year requirement. The schedule
shall include twenty-four months of full-time hospital training in an acceptable Oral and Maxillofacial Surgery
residency program. Not less than four (4) months of this period must be devoted to training in anesthesiology.
The TN-DEN must be completed by the Dean of the dental school or head of the Oral and Maxillofacial
Surgery Department of the hospital or clinic in which the Oral and Maxillofacial Surgery took place.

2. Submit evidence of certification as a full American Board Diplomate (original letter from American Specialty
Board verifying passing scores for both the written portion and the clinical portion).

3. Fee payment must be in the form of a check or money order made payable to the Illinois Department of Financial
and Professional Regulation. See REFERENCE SHEET (CHART I) for fee payment amount.

4. Forward application, supporting documentation, and fee payment to: Illinois Department of Financial and Professional
Regulation, ATTN: Division of Professional Regulation, P.O. Box 7007, Springfield, Illinois 62791.

Dental Specialist - Page 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.

IMPORTANT NOTICE: These Restoration Instructions apply only to those dental specialists 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 1-800-560-6420 for detailed instructions on how to restore it to active status.

NOTE: If you have not maintained an active practice in another jurisdiction, you will be required to successfully
complete the Clinical examination.

1. Supporting Document RS must be completed. If this form was not included in the application packet, you must
obtain one by contacting the Department of Financial and Professional Regulation at 1-800-560-6420.

2. Supporting Document CT verifying current licensure in another U.S. jurisdiction must be submitted. You are
authorized to photocopy this form if necessary. The licensing agency/board must return Supporting Document
CT to you for inclusion with your application.

3. Supporting Document VE must be completed to provide documentation of active practice in another jurisdiction
for three of the last five years. If this form was not included in the application packet, you must obtain one by
contacting the Department of Financial and Professional Regulation at 1-800-560-6420. Direct employer to return
form to you in a sealed envelope.

4. Submit copy of DD214 if restoring after military service.

5. Fee payment amount is indicated in the Official Use Only Box on Supporting Document RS. Fee payment must
be in the form of a check or money order made payable to the Illinois Department of Financial and Professional
Regulation. See REFERENCE SHEET (CHART I) for fee payment amount.

6. Forward application, supporting documentation, and fee payment to: Illinois Department of Financial and
Professional Regulation, ATTN: Division of Professional Regulation, P.O. Box 7007, Springfield, Illinois 62791.

Dental Specialist - Page 3

 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 and fees if prevailing circumstances necessitate such action.

CHART I - PROFESSION NAME, PROFESSION CODE, LICENSURE METHOD & FEE

PROFESSION PROFESSION LICENSURE APPLICATION

NAME CODE METHOD FEE

Dental Specialist 021 NON - Examination $300.00

CHARTS II and III - EXAMINATION INFORMATION AND CODES

NOT APPLICABLE FOR DENTAL SPECIALIST

ENTER N/A IN PART VII a, b, c) OF
APPLICATION FOR LICENSURE AND/OR EXAMINATION

CHART IV - SCHOOL CODES

NOT APPLICABLE FOR DENTAL SPECIALIST

ENTER N/A IN PART VII c) OF APPLICATION FOR LICENSURE AND/OR EXAMINATION

* * * * * REQUEST FOR ASSISTANCE * * * * *

If assistance is needed, direct your request to the following telephone number:

1-800-560-6420
Telecommunicative Device for the Deaf (TTY) 1-866-325-4949
Please allow 3 weeks from mailing your application before making an inquiry concerning its status.

DPR-DN-SP 4/15
 Illinois Department of Financial and Professional Regulation
Division of Professional Regulation
Application Checklist for Licensed Specialist in Dentistry

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED
with the application and required fee unless otherwise directed in the instructions.
Before you mail your application, check the following items to make sure your application is complete!
FOUR-PAGE APPLICATION REVIEW COMPLETED
Part I. Application Category Information
Part II. Applicant Identifying Information
Part III. Education Information
Part IV. Record of Licensure Information
Part V. Record of Examination
Part VI. Personal History Information
Part VII. Examination Coding Information (if applicable)
Part VIII. Child Support and/or Student Loan Information
Part IX. Certifying Statement--Signed and Dated
SUPPORTING DOCUMENTS SUBMITTED

Application Fee

Supporting Document PHQ must be completed and submitted with each application.
Your application will not be processed without completion of this form.

TN-DEN Form with seal and signature affixed; or official transcripts for specialty
training with seal affixed.

Specialty Exam Scores

Certification/American Board Diplomate (original letter from American Specialty Board)

veriying passing scores on both parts (written and oral)

Proof of Name Change (if applicable)

RS (Restoration) Form (restoration method only)

All supporting documents may not be required. Please refer to application instructions
for your specific method of licensure.
IL486-1971 (DN-SP) 12/23
This page intentionally left blank
for double-sided printing.
 IMPORTANT NOTICE: Completion of this form is
APPLICATION FOR necessary for consideration for licensure under 225 of the
Illinois Compiled Statutes. Disclosure of this information
LICENSURE AND/OR EXAMINATION 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/ Carefully follow all steps outlined on the INSTRUCTION SHEET. In addition,
or Examination in Illinois: note the following:
1. Four page APPLICATION FOR LICENSURE and /or EXAMINATION. A. Type or print legibly with black ink only.
2. INSTRUCTION SHEET, which gives step by step application B. FEES ARE NOT REFUNDABLE.
instructions for your profession.
C. Disclosure of your U.S. social security number, if you have one, is mandatory,
3. REFERENCE SHEET, which gives detailed coding information for in accordance with 5 Illinois Compiled Statutes 100/10-65 to obtain a license.
your profession. The social security number may be provided to the Illinois Department of
4. SUPPORTING DOCUMENTS, forms, and/or any other documentation Public Aid to identify persons who are more than 30 days delinquent in
you may be required to submit with your application. complying with a child support order, or to the Illinois Department of Revenue
5. If the name shown on your supporting documents is different from to identify persons who have failed to file a tax return, pay tax, penalty or
that shown on your application, you must submit PROOF OF LEGAL interest shown in a filed return, or to pay any final assessment or tax penalty
NAME change - copy of marriage license, divorce decree, affidavit or or interest, as required by any tax Act administered by the Illinois Department
court order. of Revenue, or to other entities for verification of identification.

PART I: Application Category Information

A. Check the box indicating the appropriate information regarding your application. Military Military Spouse Not Military Decline to Answer
Military service member is defined 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 Officer, or Proof of Service document from the
Servicemember's electronic personnel portal. Proof for Spouses: Military Permanent Change of Station Orders with the spouse identified by name; Official
Notification of Change of Assignment with your marriage license, a certified DD1172 verifying marital status, or a letter signed by the commanding officer verifying
change of assignment and the name of the military spouse.
B. 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
$
C. 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 denied
profession in Illinois. in Illinois. I am reapplying since I have fulfilled additional
I have previously made application for this profession in requirements.
Illinois. However, my previous application expired and I I have previously made application for this profession in
am 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. SSN TO ITIN

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. REQUIRED
Work: ( __ __ __ ) __ __ __ __ __ __ __ __ Home: ( __ __ __ ) __ __ __ __ __ __ __ __ E-MAIL ADDRESS
(Area Code) (Area Code)
Fax: ( __ __ __ ) __ __ __ __ __ __ __
__
Fax: ( __ __ __ ) __ __ __ __ __ __ __ __
(Area Code) (Area Code)
IL486-1019 12/23 (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.illinois.gov
 NAME (Last, First, MI):
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)

___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

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

 NAME (Last, First, MI):
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 Licen-
sure 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

___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

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 APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 3 of 4
 NAME (Last, First, MI):
PART VI: Personal History Information (This part must be completed by all applicants) YES NO
1. Have you been convicted of or pled guilty or nolo contendere to any criminal offense in any state or in federal court? Please do not give
details on minor traffic charges, but do include information relating to Driving While Intoxicated (DWI) charges. If yes, attach a personal
statement describing the circumstances of the conviction and certified copies of court records of your conviction including the nature of
the offense, date of discharge, and a statement from the probation or parole office. In general, a criminal conviction by itself does not
usually result in denial of licensure.

2. Have you been convicted of a felony? In general, a felony conviction by itself does not usually result in denial of licensure.

___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

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. Do you now have any disease or condition that presently limits 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? 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 Tax 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 ILCS 2105-15(g), "The Department shall deny any license application or renewal authorized under any licensing Act
administered by the Department to any person who has failed to file a return, or to pay the tax, penalty, or interest shown in a filed return, or to
pay any final assessment of tax, penalty, or interest, as required by any tax Act administered by the Illinois Department of Revenue, until such
time as the requirement of any such tax Act is satisfied."

Are you delinquent in the filing of state taxes? 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 APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 4 of 4
 SUPPORTING DOCUMENT
IMPORTANT NOTICE: Completion of
this form is necessary to accomplish the HEALTH CARE WORKERS
requirements outlined in 20 ILCS 2105 of
the Civil Administrative Code. Disclosure of ADDITIONAL PERSONAL HISTORY PHQ
this information is REQUIRED.
QUESTIONS
1. NAME LAST FIRST MIDDLE 3. PROFESSIONAL LICENSE NUMBER (if any)
__ __ __ - __ __ __ __ __ __
2. ADDRESS STREET, CITY, STATE, ZIP CODE 4. SOCIAL SECURITY NUMBER OR ITIN
__ __ __ - __ __ - __ __ __ __
Pursuant to 20 ILCS 2105-165(a), the Department requires the following professionals to disclose information regarding charges or
convictions pertaining to certain offenses. Please check applicable profession.
Acupuncturist Naprapath Psychologist, Clinical (LCP)
Advanced Practice Registered Nurse Nursing Home Administrator Podiatrist
Advanced Practice Registered Occupational Therapist Prosthetist
Nurse - Full Practice Authority Registered Nurse
Occupational Therapy Assistant
Athletic Trainer Registered Surgical Assistant
Optometrist
Audiologist Registered Surgical Technologist
Orthotist
Behavior Analyst Respiratory Care Practitioner
Pedorthist
Behavior Analyst Assistant Sex Offender Associate
Perfusionist
Certified Midwife Sex Offender Evaluator
Pharmacist
Chiropractic Physicians (D.C.) Sex Offender Treatment Provider
Physical Therapist
Dental Hygienist Social Worker (LSW)
Physical Therapy Assistant
Dentist Physicians, including Medical Social Worker, Clinical (LCSW)
Genetic Counselor Doctors (M.D.), Doctors of Speech Pathologist
Licensed Practical Nurse Osteopathic Medicine (D.O.)
Marriage and Family Therapist Physician Assistant
Marriage and Family Therapist Assoc. Professional Counselor (LPC)
Music Therapist Professional Counselor, Clinical
(LCPC)

Any other license issued by the Department under the Acts listed in this Section and the Controlled Substances Act [740 ILCS 40], except for pharmacy
technicians, issued to a person subject to the Code and this Part.

In order for your application to be evaluated, you must respond to each of the following questions:

1) Are you currently charged with or have you been convicted of a criminal act that requires registration Yes No
under the Sex Offender Registration Act? *
2) Are you currently charged with or have you been convicted of a criminal battery against any patient in the
course of patient care or treatment, including any offense based on sexual conduct or sexual penetration?

3) Are you required, as part of a criminal sentence, to register under the Sex Offender Registration Act? *

4) Are you currently charged with or have you been convicted of a forcible felony? *

If YES to any of the above, attach a personal statement describing the circumstances of the charge or conviction and
a certified copy of the court records regarding your charge or conviction, including the nature of the offense and date of
discharge, if applicable, as well as a statement from the probation or parole office.

Certification Statement

Under penalties of perjury, I declare that I have examined this Form and all supporting documents and/or information
submitted by me in connection therewith, and to the best of my knowledge, they are true, correct, and complete.

Signature of Applicant Email Date

IL486-2034 12/23 Page 1of 3
 * DEFINITIONS

730 ILCS 150 et. seq:—Acts that require Sex Offender Registration:
(B) As used in this Article, “sex offense” means:
(1) A violation of any of the following Sections of the Criminal Code of 1961:
11-20.1 (child pornography),
11-20.3 (aggravated child pornography),
11-6 (indecent solicitation of a child),
11-9.1 (sexual exploitation of a child),
11-9.2 (custodial sexual misconduct),
11-9.5 (sexual misconduct with a person with a disability),
11-15.1 (soliciting for a juvenile prostitute),
11-18.1 (patronizing a juvenile prostitute),
11-17.1 (keeping a place of juvenile prostitution),
11-19.1 (juvenile pimping),
11-19.2 (exploitation of a child),
11-25 (grooming),
11-26 (traveling to meet a minor),
12-13 (criminal sexual assault),
12-14 (aggravated criminal sexual assault),
12-14.1 (predatory criminal sexual assault of a child),
12-15 (criminal sexual abuse),
12-16 (aggravated criminal sexual abuse),
12-33 (ritualized abuse of a child).
An attempt to commit any of these offenses.
(1.5) A violation of any of the following Sections of the Criminal Code of 1961, when the victim is a person under 18 years of age, the
defendant is not a parent of the victim, the offense was sexually motivated as defined in Section 10 of the Sex Offender Management
Board Act, and the offense was committed on or after January 1, 1996:
10-1 (kidnapping),
10-2 (aggravated kidnapping),
10-3 (unlawful restraint),
10-3.1 (aggravated unlawful restraint).
(1.6) First degree murder under Section 9-1 of the Criminal Code of 1961, when the victim was a person under 18 years of age and the
defendant was at least 17 years of age at the time of the commission of the offense, provided the offense was sexually motivated as
defined in Section 10 of the Sex Offender Management Board Act.
(1.7) (Blank).
(1.8) A violation or attempted violation of Section 11-11 (sexual relations within families) of the Criminal Code of 1961, and the offense
was committed on or after June 1, 1997.
(1.9) Child abduction under paragraph (10) of subsection (b) of Section 105 of the Criminal Code of 1961 committed by luring or
attempting to lure a child under the age of 16 into a motor vehicle, building, house trailer, or dwelling place without the consent of the
parent or lawful custodian of the child for other than a lawful purpose and the offense was committed on or after January 1, 1998,
provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.
(1.10) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed on
or after July 1, 1999:
10-4 (forcible detention, if the victim is under 18 years of age), provided the offense was sexually motivated as defined
in Section 10 of the Sex Offender Management Board Act,
11-6.5 (indecent solicitation of an adult),
11-15 (soliciting for a prostitute, if the victim is under 18 years of age),
11-16 (pandering, if the victim is under 18 years of age),
11-18 (patronizing a prostitute, if the victim is under 18 years of age),
11-19 (pimping, if the victim is under 18 years of age).
(1.11) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed on
or after August 22, 2002:
11-9 (public indecency for a third or subsequent conviction).
(1.12) A violation or attempted violation of Section 5.1 of the Wrongs to Children Act (permitting sexual abuse) when the offense was
committed on or after August 22, 2002.
(2) A violation of any former law of this State substantially equivalent to any offense listed in subsection (B) of this Section.
(C) A conviction for an offense of federal law, Uniform Code of Military Justice, or the law of another state or a foreign country that is
substantially equivalent to any offense listed in subsections (B), (C), (E), and (E5) of this Section shall constitute a conviction for the
purpose of this Article.

IL486-2034 02/13 (crimacts) Page 2 of 3

 * DEFINITIONS

A “forcible felony”, for the purposes of Section 2105-165 of the Code (section numbers are from
the Criminal Code of 1961 [720 ILCS 5]) and 68 Illinois Administrative Code 1130.120 is one or
more of the following offenses:

a) First Degree Murder (Section 9-1);

b) Intentional Homicide of an Unborn Child (Section 9-1.2);
c) Second Degree Murder (Section 9-2);
d) Voluntary Manslaughter of an Unborn Child (Section 9-2.1);
e) Drug-induced Homicide (Section 9-3.3);
f) Kidnapping (Section 10-1);
g) Aggravated Kidnapping (Section 10-2);
h) Unlawful Restraint (Section 10-3);
i) Aggravated Unlawful Restraint (Section 10-3.1);
j) Forcible Detention (Section 10-4);
k) Involuntary Servitude (Section 10-9(b));
l) Involuntary Sexual Servitude of a Minor (Section 10-9(c));
m) Trafficking in Persons (Section 10-9(d));
n) Criminal Sexual Assault (Section 11-1.20);
o) Aggravated Criminal Sexual Assault (Section 11-1.30);
p) Predatory Criminal Sexual Assault of a Child (Section 11-1.40);
q) Criminal Sexual Abuse (Section 11-1.50);
r) Aggravated Criminal Sexual Abuse (Section 11-1.60);
s) Aggravated Battery (Section 12-3.05);
t) Compelling Organization Membership of Persons (Section 12-6.5);
u) Compelling Confession or Information by Force or Threat (Section 12-7);
v) Home Invasion (Section 12-11);
w) Robbery (Section 18-1);
x) Armed Robbery (Section 18-2);
y) Vehicular Hijacking (Section 18-3);
z) Aggravated Vehicular Hijacking (Section 18-4);
aa) Aggravated Robbery (Section 18-5);
bb) Terrorism (Section 29D-14.9);
cc) Causing a Catastrophe (Section 29D-15.1);
dd) Possession of a Deadly Substance (Section 29D-15.2);
ee) Making a Terrorist Threat (Section 29D-20);
ff) Falsely Making a Terrorist Threat (Section 29D-25);
gg) Material Support for Terrorism (Section 29D-29.9);
hh) Hindering Prosecution of Terrorism (Section 29D-35);
ii) Boarding or Attempting to Board an Aircraft with Weapon (Section 29D-35.1);
jj) Armed Violence (Section 33A-2); and
kk) Attempt (Section 8-4) of any of the above specified offenses.

IL486-2034 02/13 (crimacts) Page 3 of 3

This page intentionally left blank
for double-sided printing.
 IMPORTANT NOTICE: Completion of this form SUPPORTING DOCUMENT
is necessary for consideration for licensure
under 225 ILCS 25/1 et. seq. (Illinois Compiled
Statutes). Disclosure of this information is
VOLUNTARY. However, failure to comply may CERTIFICATION OF TRAINING TN-DEN
result in this form not being processed.

APPLICANT: Complete the applicant section of this form. Forward the form to the individual who will certify your
training.
1. NAME LAST FIRST MIDDLE 2. DATE OF BIRTH 3. SSN OR ITIN
__ __ / __ __ / __ __ __ __
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. DATES OF TRAINING 8. ISSUANCE DATE

NUMBER (If Applicable) ISSUANCE DATE (If Applicable)
From __ __/__ __/__ __ __ __ To __ __/__ __/__ __ __ __
Month Day Year Month Day Year
9. SPECIFIC NAME OF TRAINING RECEIVED 10. SUPERVISOR/INSTRUCTOR NAME

DIRECTOR/ADMINISTRATOR: Complete the remainder of this form. Return the completed form to the applicant.

A. SUPERVISOR/INSTRUCTOR NAME B. INSTITUTION/BUSINESS NAME

C. SUPERVISOR/INSTRUCTOR JOB TITLE/PROFESSION NAME D. INSTITUTION/BUSINESS STREET ADDRESS

E. SUPERVISOR/INSTRUCTOR LICENSE OR CERTIFICATE NO. F. INSTITUTION/BUSINESS CITY, STATE, ZIP CODE

G. SUPERVISOR/INSTRUCTOR STATE OF LICENSURE OR H. INSTITUTION/BUSINESS TELEPHONE NUMBER

CERTIFYING ASSOCIATION NAME
Area Code (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
I. RECORD ANY ADDITIONAL COMMENTS YOU WISH TO MAKE REGARDING THE APPLICANT'S TRAINING.

IL486-1552 12/23 (LT) COMPLETE EITHER SECTION I OR II TN-DEN Certification of Training - Page 1 of 2
ON THE SECOND PAGE OF THIS FORM
 NAME (Last, First, MI):
I. DENTAL SPECIALTY TRAINING:
Certifying Official, i.e., Director of Program, or Dean of the dental school or the head of the Oral and
Maxillofacial Surgery Department of the hospital or clinic: Complete the remainder of this form. Return the
completed form to the applicant.
A. APPLICANT'S TRAINING DATES B. TRAINING CLOCK HOURS COMPLETED
From __ __/__ __/__ __ __ __ To __ __/__ __/__ __ __ __ Clinical ______ Didactic ______ TOTAL ______
Month Day Year Month Day Year
C. SPECIALIZATION NAME IN WHICH APPLICANT TRAINED D. DID APPLICANT SUCCESSFULLY COMPLETE TRAINING
COURSE?

___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

Yes No
E. IF TRAINING WAS OBTAINED OUTSIDE OF AN INSTITUTION FACILITY, INDICATE THE SETTING(S) IN WHICH TRAINING WAS
OBTAINED.

II. ANESTHESIOLOGY TRAINING:

Director/Administrator: Verify only the anesthesiology training program inclusive of training hours in
clinical and didactic. Return the completed form to the applicant.
A. APPLICANT'S TRAINING DATES B. TRAINING CLOCK HOURS COMPLETED
From __ __/__ __/__ __ __ __ To __ __/__ __/__ __ __ __ Clinical ______ Didactic ______ TOTAL ______
Month Day Year Month Day Year
C. SPECIALIZATION NAME IN WHICH APPLICANT TRAINED D. DID APPLICANT SUCCESSFULLY COMPLETE TRAINING
COURSE?
Yes No
E. IF TRAINING WAS OBTAINED OUTSIDE OF AN INSTITUTION FACILITY, INDICATE THE SETTING(S) IN WHICH TRAINING WAS
OBTAINED.

I certify that the information recorded herein is true and correct according to the official records of this institution.

Print Name of School Official Signature of School Official and/or Director/Administrator

of Training Programs

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

IL486-1552 (LT) TN-DEN Certification of Training - Page 2 of 2