Nurse Certification Of Education Form (Ed-Nur) - Continental Testing Services

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SUPPORTING DOCUMENT
IMPORTANT NOTICE: Completion of this
form is necessary for consideration for
licensure under 225 ILCS 65/1 et.seq. of
ED-NUR
(Illinois 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 official 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, then return to the
applicant.
A. NAME OF INSTITUTION
B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE
C. DEPARTMENT OF INSTITUTION
D. MAJOR AREA OF STUDY OF THE APPLICANT
E. DATES OF ATTENDANCE
From
To
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
F.
G.TYPE OF DEGREE OR CERTIFICATE AWARDED (e.g., BA., MA.,
Total academic years attended
Ph.D.)
Years
Months
Days
OR
Total calendar years attended
Years
Months
Days
H. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS WERE MET
I. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
Month
Day
Year
Month
Day
Year
J. IF EDUCATION PROGRAM WAS COMPLETED IN LESS THAN THE NORMALLY REQUIRED TIME, PLEASE EXPLAIN:
IL486-1031 07/04 (NS)
ED-NUR - Certification of Education - Page 1 of 2

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