Form Il486-1019 - Application For Licensure And/or Examination (Page 11 of 22) in pdf

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.

Carefully follow all steps outlined on the INSTRUCTION SHEET. In

The following materials are required to make Application for

addition, note the following:

Licensure and/or Examination in Illinois:

A. Type or print legibly with black ink only.

Four page APPLICATION FOR LICENSURE AND/OR

EXAMINATION.

B. FEES ARE NOT REFUNDABLE.

INSTRUCTION SHEET, which gives step by step ap-

C. Disclosure of your U.S. social security number, if you have one, is

plication instructions for your profession.

mandatory, in accordance with 5 Illinois Compiled Statutes 100/10-65

REFERENCE SHEET, which gives detailed coding

to obtain a license. The social security number may be provided to

information for your profession.

the Illinois Department of Public Aid to identify persons who are more

SUPPORTING DOCUMENTS, forms, and/or any other

than 30 days delinquent in complying with a child support order, or

documentation you may be required to submit with

to the Illinois Department of Revenue to identify persons who have

your application.

failed to ﬁ le a tax return, pay tax, penalty or interest shown in a ﬁ led

return, or to pay any ﬁ nal assessment or tax penalty or interest, as

If the name shown on your supporting documents is differ-

required by any tax Act administered by the Illinois Department of

ent from that shown on your application, you must submit

Revenue, or to other entities for veriﬁ cation of identiﬁ cation.

PROOF OF LEGAL NAME change - copy of marriage

license, divorce decree, afﬁ davit or court order.

PART I: Application Category Information

A. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4

3. LICENSURE METHOD

4. FEE

1. PROFESSION NAME

2. PROFESSION CODE

B. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION

This is the ﬁ rst 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 fulﬁ lled additional

requirements.

I have previously made application for this profession in

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

ﬁ le this application in order to receive any further information.

1. NAME

LAST

FIRST

MIDDLE

3. UNITED STATES SOCIAL SECURITY NO.

2. TITLE (e.g., M.D., D.D.S., etc.)

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

Male

Day

Year

Month

11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED

12.

REQUIRED

Work: ( __ __ __ ) __ __ __

__ __ __ __

Home: ( __ __ __ ) __ __ __

__ __ __ __

E-MAIL ADDRESS

(Area Code)

Fax:

( __ __ __ ) __ __ __

__ __ __ __

Fax:

( __ __ __ ) __ __ __

__ __ __ __

(Area Code)

IL486-1019 08/16 (LT)

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4

Additional application forms can be downloaded from the IDFPR Web site at

Form Il486-1019 - Application For Licensure And/or Examination Page 11

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