Form Il486-1019 - Application For Licensure And/or Examination Page 16
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22PART III - CERTIFICATION OF EXAMINATION SCORES
A1. National or other Profession Specifi c Examination
Date of Examination
___________________
(Record all available information)
Scaled Score
__________________
Raw Score
___________________
Standard Deviation
__________________
Corrected Score
___________________
National Mean
__________________
Percent Score
___________________
A 2.
SUBJECT
DATE
SCORE
SUBJECT
DATE
SCORE
B. State Constructed Examination
SUBJECT
DATE
SCORE
SUBJECT
DATE
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 fi ne, reprimand, probation, censure, revocation, suspension,
surrender, restriction or limitation? (If yes, attach a certifi ed copy of disciplinary action.)
Yes
No
PART V - RECIPROCAL REGISTRATION
This state
does
does not
grant the same privilege of reciprocal registration to Illinois registrants.
I certify that the information contained herein is true and correct according to the offi cial records of the State.
Print Name
S E A L
Title
Signature
Date
Agency/Board Street Address
Area Code (
)
City, State, ZIP Code
Telephone Number
Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT.
Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.
IL486-0850 04/06 (LT)
CT - Certifi cation by Licensing Agency/Board - Page 2 of 2
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