Form Il486-1019 - Application For Licensure And/or Examination Page 17
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22IMPORTANT NOTICE: Completion of
SUPPORTING DOCUMENT
this form is necessary for consideration
for licensure under 225 of the Illinois
ED
Compiled Statutes. Disclosure of this
CERTIFICATION OF EDUCATION
information is VOLUNTARY. However,
failure to comply may result in this form
not being 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 offi cial 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. RETURN THE COMPLETED
FORM TO THE APPLICANT.
A. NAME OF INSTITUTION
B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE
C. DEPARTMENT OF INSTITUTION
D. SPECIFIC PROGRAM OR CURRICULUM CONCENTRATION OF
APPLICANT
E. MAJOR AREA OF STUDY OF THE APPLICANT
F. APPLICANT WAS (CHECK ONE):
Full-time
Part-time
Co-op
G. CREDIT HOURS EARNED
H. DATES OF ATTENDANCE
_________ Semester Hours
(CHECK ONE AND
COMPLETE)
_________ Quarter Hours
From __ __ /__ __ /__ __ __ __
To __ __ /__ __ /__ __ __ __
_________ Course Hours
Month
Day
Year
Month
Day
Year
J. TYPE OF DEGREE OR CERTIFICATE AWARDED
I.
Total academic years attended _____ _____ _____
(e.g., B.A., M.A., M.D., Ph.D.)
Years
Months
Days
OR
Total calendar years attended
_____ _____ _____
Years
Months
Days
K. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS WERE MET
L. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
Month
Day
Year
Month
Day
Year
M. CHECK THE APPROPRIATE STATEMENT(S) AND COMPLETE
Applicant has graduated on __ __ /__ __ /__ __ __ __
Applicant has completed program on __ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
Applicant will graduate on
__ __ /__ __ /__ __ __ __
Applicant will complete program on
__ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
N. IF EDUCATION PROGRAM WAS COMPLETED IN LESS THAN THE NORMALLY REQUIRED TIME, PLEASE EXPLAIN:
ED - Certifi cation of Education - Page 1 of 2
IL486-1306 03/06 (LT)
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