Form Il486-1019 - Application For Licensure And/or Examination Page 19
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22SUPPORTING DOCUMENT
IMPORTANT NOTICE: Completion of
this form is necessary to accomplish the
requirements outlined in 225 of the Illinois
VERIFICATION OF
VE
Compiled Statutes. Disclosure of this
EMPLOYMENT / EXPERIENCE
information is VOLUNTARY. However,
failure to comply may result in this form not
being processed.
APPLICANT: Complete the application section of this form, then forward it to your employer. Upon receipt of the
completed form from the employer, include it with your Application for Licensure/Examination. You
are authorized to photocopy this form as necessary.
3. SOCIAL SECURITY NUMBER
2. DATE OF BIRTH
1. NAME
LAST
FIRST
MIDDLE
__ __ __ - __ __ - __ __ __ __
__ __ / __ __ / __ __ __ __
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. JOB TITLE OR POSITION APPLICANT HELD
9. SUPERVISOR NAME
8. DATES OF EMPLOYMENT
From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __
Month
Day
Year
Month
Day
Year
EMPLOYER:
Complete the remainder of this form. Return the completed form to the applicant in a sealed
envelope.
PART I - EMPLOYMENT INFORMATION
A. EMPLOYER NAME
B. BUSINESS / INSTITUTION NAME
C. EMPLOYER REGISTRATION/LI-
D. STATE OF EMPLOYER
E. BUSINESS ADDRESS
STREET
CITY
STATE
ZIP CODE
CENSE NUMBER
REGISTRATION/LICENSE
F. BUSINESS REGISTRATION/LI-
G. STATE OF BUSINESS
H. BUSINESS TELEPHONE NUMBER
CENSE NUMBER (If Applicable)
REGISTRATION/LICENSE
_
Area Code (___ ___ ___) ___ ___ ___
___ ___ ___ ___
PART II - APPLICANT EMPLOYMENT INFORMATION
C. DATES OF EMPLOYMENT
A. NUMBER OF HOURS WORKED
B. TYPE OF EMPLOYMENT
PER WEEK
From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __
[ ]Full-time
[ ]Part-time
Month
Day
Year
Month
Day
Year
D. RECORD APPLICANT'S POSITION TITLE(S)
E. GIVE BRIEF DESCRIPTION OF DUTIES PERFORMED BY THE APPLICANT.
I do hereby declare that this information is true and correct.
Signature
Date
Title
IL486-1348 04/06 (L&T)
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