OP.indd

PACKET UPDATED 5/29/24

DPR-OP 5/24

Applicants applying for licensure on the basis of Acceptance of Examination, Endorsement or Restoration must be

eligible for Diagnostic Ocular Phamaceuticals (TN-D-OPT), Topical Therapeutics (TN-T-OPT) and Oral Therapeutic

Medications (TN-T-OPT Oral Therapeutics).

Those doctors wishing to prescribe controlled substance medications must complete and return the enclosed Illinois

Controlled Substance application and upon issuance may apply for a DEA license.

FOR MAKING APPLICATION UNDER PROVISIONS OF THE

ILLINOIS OPTOMETRIC ACT

Acceptance of Examination

Endorsement

Restoration

INSTRUCTIONS

BEFORE COMPLETING THE APPLICATION PACKAGE, read each of the 4 steps below in the order that

they are listed, then follow the directions as they apply to you. This will aid you in completing your application

accurately and eliminate any delay in processing. THE APPLICATION WHICH YOU SUBMIT IS VAL-

ID FOR THREE YEARS FROM DATE OF RECEIPT. If you are issued a license, please be advised that your

license will expire March 31st of each even-numbered year.

Step 1. Use the REFERENCE SHEET (CHART I) to select the appropriate Profession Name, 3 digit Pro-

fession Code, Licensure Method and Fee, and record that information in PART I (page one) of

the Application for Licensure and/or Examination.

Step 2. Proceed with PART II (page one) and complete all applicable information requested on all 4 pages of

the Application for Licensure and/or Examination.

Step 3. The remainder of this form contains speciﬁ c instructions for each Licensure Method. Locate the instruc-

tions for the Licensure Method you recorded on PART I (page one), of the Application for Licensure

and/or Examination and follow those instructions only.

NOTE: All documents in a foreign language that are required to be submitted with an application

or for any other purpose in connection with licensure must be accompanied by an original,

notarized translation that has been performed by a person, other than the applicant, who is

ﬂ uent in both English and the language of the document(s). The translator shall certify to

the above requirements as well as to the accuracy of the translation.

Step 4. If needed, telephone numbers for assistance in completing the Application Package are provided on the

REFERENCE SHEET.

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov.

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

ACCEPTANCE OF EXAMINATION

NOTE: Complete and return this application and all supporting documents and instruct the National Board of

Examiners in Optometry (N.B.E.O.) to forward your scores directly to the Department when you have

successfully completed all parts of the National Board including passage of the Treatment and Management

of Ocular Disease (T.M.O.D.).

1. Supporting Document PHQ must be completed and submitted with each application. Your application will not

be processed without completion of this form.

2. Supporting Document ED must be completed by the dean or registrar of the optometry education

program attended with the school seal aﬃ xed. Must be submitted with each application.

3. Supporting Document TN-D-OPT ;TN-T-OPT and TN-T-ORALS must be completed if you graduated from

an approved school of Optometry before January 1, 1984.

4. Supporting Document TN-D-OPT and TN-T-ORALS must be completed if you graduated from an approved

school of Optometry from January 1, 1984 thru December 31, 1993.

5. Supporting Document TN-T-ORALS must be completed if you graduated from an approved school of Optometry

from January 1, 1994 thru December 31, 2007.

6. If you graduated January 1, 2008 and forward, only Supporting Document ED is required.

7. If you have ever been licensed as an optometrist, Supporting Document CT must be completed by the jurisdic-

tion of the original licensure and current licensure which you have been issued a license. You are authorized

to photocopy the form if necessary. You must direct the licensing agency/board to return completed form CT

directly to you.

8. A certiﬁ ed copy of your National Board of Examiners in Optometry (NBEO) score must be sent directly to this

Division from NBEO indicating that you passed both parts of the written theoretical examination, including

TMOD, and the clinical skills examination.

9. Fee payment is indicated on the REFERENCE SHEET, CHART I. Fee payment must be in the form of a check

or money order made payable to Department of Financial and Professional Regulation.

10. Forward four-page application, supporting documentation, and fee payment to: Illinois Department of Financial

and Professional Regulation, Attn: Division of Professional Regulation, P.O. 7007, Springﬁ eld, Illinois 62791.

OPTOMETRIST- PAGE 2

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

Applicants applying for licensure on the basis of Acceptance of Examination, Endorsement or Restoration must be

eligible for Diagnostic Ocular Phamaceuticals (TN-D-OPT), Topical Therapeutics (TN-T-OPT) and Oral Therapeutic

Medications (TN-T-OPT Oral Therapeutics).

Those doctors wishing to prescribe controlled substance medications must complete and return the enclosed Illinois

Controlled Substance application and upon issuance may apply for a DEA license.

NOTE: Based on the Illinois Optometric Licensing and Disciplinary Board evaluation of your application and

supporting documents, you may be required to submit additional documentation. Your application

evaluation is based upon the equivalency of your examination results in the previous jurisdiction compared

to the Illinois examination administered the same year.

1. Supporting Document PHQ must be completed and submitted with each application. Your application will not be

processed without completion of this form.

2. Supporting Document ED must be completed by the dean or registrar of the optometry education

program attended with the school seal aﬃ xed. Must be submitted with each application.

3. Supporting Document TN-D-OPT ;TN-T-OPT and TN-T-ORALS must be completed if you graduated from

an approved school of Optometry before January 1, 1984.

4. Supporting Document TN-D-OPT and TN-T-ORALS must be completed if you graduated from an approved

school of Optometry from January 1, 1984 thru December 31, 1993.

5. Supporting Document TN-T-ORALS must be completed if you graduated from an approved school of Optometry

from January 1, 1994 thru December 31, 2007.

6. If you graduated January 1, 2008 and forward, only Supporting Document ED is required.

7. If you have ever been licensed as an optometrist, Supporting Document CT must be completed by the jurisdic-

tion of the original licensure and current licensure which you have been issued a license. You are authorized

to photocopy the form if necessary. You must direct the licensing agency/board to return completed form CT

directly to you.

8. A certiﬁ ed copy of your National Board of Examiners in Optometry (NBEO) score must be sent directly to this

Division from NBEO indicating that you passed both parts of the written theoretical examination, including

TMOD, and the clinical skills examination.

9. Submit a copy of the licensing Acts and Rules for registration in the jurisdiction of original licensure for the

time you were licensed.

10. Fee payment is indicated on the REFERENCE SHEET, CHART I. Fee payment must be in the form of a check

or money order made payable to Department of Financial and Professional Regulation.

11. Forward four-page application, supporting documentation, and fee payment to: Illinois Department of Financial

and Professional Regulation, Attn: Division of Professional Regulation, P.O. 7007, Springﬁ eld, Illinois 62791.

ENDORSEMENT

OPTOMETRIST - PAGE 3

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

Applicants applying for licensure on the basis of Acceptance of Examination, Endorsement or Restoration must be

eligible for Diagnostic Ocular Phamaceuticals (TN-D-OPT), Topical Therapeutics (TN-T-OPT) and Oral Therapeutic

Medications (TN-T-OPT Oral Therapeutics).

Those doctors wishing to prescribe controlled substance medications must complete and return the enclosed Illinois

Controlled Substance application and upon issuance may apply for a DEA license.

OPTOMETRY RESTORATION

NOTE: Based on the Illinois Optometric Licensing and Disciplinary Board evaluation of your application and supporting documents, you

may be required to submit additional documentation.

1. Supporting Document PHQ must be completed. If this form was not included in the application packet, they must obtain one by con-

tacting the DPR Call Center at 1-800-560-6420.

2. Supporting Document RS must be completed by each state in which you have ever been issued a license. You are authorized to photo-

copy the form if necessary. You must direct the licensing agency/board to return completed form CT directly to the address indicated in

number 9 below.

3. Submit one of the following documents:

a) Supporting Document CT must be completed by the jurisdiction of original licensure and current

licensure in which they have been issued a license. You are authorized to photocopy the form if

necessary. You may direct the licensing agency/board to return the completed form CT directly to you.

AND

Supporting Document VE must be completed by your employer to verify current active practice in

another jurisdiction. If self-employed, complete the document on your own behalf. If this form is not

included in the application packet, the applicant must obtain one by contacting the Division of

Professional Regulation at 1-800-560-6420. OR

b) If restoring after active military service, submit a copy of DD214.

4. If unable to submit supporting documents VE or form DD214, proof of completion of one of the following must be submitted:

a) Evidence of other education or other experience acceptable to the Division of the licensee's ﬁ tness to

have the certiﬁ cation restored. Such evidence shall be reviewed on a case by case basis by the Board;

b) Certiﬁ cation of passage of Part III of the examination administered by the NBEO.

5. Submit the following documents:

a) Evidence of an existing Therapeutic Pharmaceutical agent certiﬁ cation at the time license was placed

in inactive or expired status; AND

b) Proof of completion of the Oral Pharmaceutical Agents requirement pursuant to Section 1320.335 of

the Rules.

6. All applicants for Restoration of optometry license in Illinois must submit proof of having met the 30-hour requirement of continuing

education during the 2 years prior to restoration. This must be veriﬁ ed by submission of certiﬁ cates of attendance provided by approved

sponsors of continuing education programs.

7. Proof of current certiﬁ cation in cardiopulmonary resuscitation (CPR).

8. Fee payment amount is indicated in the Oﬃ cial Use Only Box on Supporting Document RS. Fee payment must be in the form of a

check or money order made payable to the Illinois Department of Financial and Professional Regulation.

9. Forward four-page application, supporting documentation and fee payment to: Illinois Department of Financial and Professional Regu-

lation, Attn: Division of Professional Regulation, P.O. 7007, Springﬁ eld, Illinois 62791.

OPTOMETRIST - PAGE 4

IMPORTANT NOTICE: These Restoration Instructions apply only to those optometrists whose licenses have been on inactive

status, or in non-renewed status, for three or more years.

If your license has been inactive, or in non-renewed status, for less than three years, you

should contact the Department of Financial and Professional Regulation Call Center at 1-800-

560-6420 for detailed instructions on how to restore it to active status.

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED

with the application and required fee unless otherwise directed in the instructions.

Applicants applying for licensure on the basis of Acceptance of Examination, Endorsement or Restoration must be eligible for Diagnostic Ocular

Phamaceuticals (TN-D-OPT), Topical Therapeutics (TN-T-OPT) and Oral Therapeutic Medications (TN-T-OPT Oral Therapeutics).

Those doctors wishing to prescribe controlled substance medications must complete and return the enclosed Illinois Controlled Substance

application and upon issuance may apply for a DEA license.

LICENSURE METHODS AND DEFINITIONS

Following are deﬁ nitions of the various methods used in issuing licenses for professionals in the

State of Illinois. Some of these licensure methods may not be applicable to your profession. Refer

to the enclosed instruction sheet to determine the speciﬁ c licensure methods/requirements for

your profession.

Licensure Methods Deﬁ nition

Examination Applicant has applied or is required to take and pass all

or a portion of an exam scheduled and/or given by the

Department or a representative of the Department.

Endorsement of License Original license issued in another state and that state's

requirements were substantially equivalent to Illinois

requirements at time license was issued.

Acceptance of Examination Applicant has taken a National Exam, referred to by

Illinois statute, in any state. Applicant may or may not be

licensed in another state.

Restoration Applicant has previously been licensed in State of Illinois

and has allowed license to lapse long enough to require

reapplication. Possible exam passage and/or committee

review.

Grandfather/Waiver Applicant will be licensed without regard to current

requirements because statute allows this based on past

qualiﬁ cation and practices (for a speciﬁ ed time only).

Non-examination Applicant is licensed by meeting qualiﬁ cations required

by statute. There is no exam for these professions.

These can be either businesses or individuals.

DPR-I-DEFINE D 7/06

IMPORTANT NOTICE

Elder and Child Abuse Reporting

"Pursuant to Public Act 91-0244, eﬀ ective January 1, 2000, if you have

reason to believe that an adult 60 years of age or older who resides

in a domestic living situation who, because of dysfunction is unable

to seek assistance for himself or herself has, within the previous 12

months been subject to abuse, neglect or ﬁ nancial exploitation, the

mandated reporter shall, within 24 hours after developing such belief,

report this suspicion to the Department on Aging. Reports should be

made to DEPARTMENT ON AGING AT 1-800-252-8966."

_____________________________________

"Public Act 91-0244 also requires that if you have reasonable cause

to believe a child known to you in your professional capacity may be

an abused or neglected child you are required to report such possible

neglect or abuse to the DEPARTMENT OF CHILDREN AND FAMILY

SERVICES AT 1-800-25abuse."

DPR-I-abuse 12/99

DPR-OP 05/14

REFERENCE SHEET

ALL FEES ARE NONREFUNDABLE

Department reserves the right to change fees if prevailing circumstances necessitate such action.

CHART I - PROFESSION NAME, PROFESSION CODE, LICENSURE METHOD & FEE

Registered Optometrist 046 Acceptance of Examination $500.00

Registered Optometrist 046 Endorsement $500.00

Registered Optometrist 046 Restoration See Supporting Document RS

PROFESSION LICENSURE APPLICATION

PROFESSION NAME CODE METHOD FEE

DPR Call Center - 1-800-560-6420

TTY - 1-866-325-4949

Please allow 6 weeks from mailing your application before making an inquiry concerning its status.

CHART II - EXAMINATION CODES AND FEES

NOT APPLICABLE FOR OPTOMETRIST

ENTER N/A IN PART VII a) OF

APPLICATION FOR LICENSURE AND/OR EXAMINATION

CHART III - EXAMINATION DATES AND LOCATION

NOT APPLICABLE FOR OPTOMETRIST

ENTER N/A IN PART VII b) OF

APPLICATION FOR LICENSURE AND/OR EXAMINATION

CHART IV - SCHOOL CODES

NOT APPLICABLE FOR OPTOMETRIST

ENTER N/A IN PART VII c) OF

APPLICATION FOR LICENSURE AND/OR EXAMINATION

If assistance is needed, direct your request to one the following telephone numbers:

* * * * * REQUEST FOR ASSISTANCE * * * * *

This is the ﬁ rst time I have made application for this

profession in Illinois.

I have previously made application for this profession in

Illinois. However, my previous application expired and I

am now reapplying.

Other:

4. PERMANENT MAILING ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY

5. BUSINESS ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY

PART I: Application Category Information

4. FEE

C. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION

3. SSN OR ITIN

6. MAIDEN, GIVEN SURNAME, OR ANY NAME(S) UNDER WHICH SUPPORTING

DOCUMENTS WILL BE SUBMITTED. (SEE INSTRUCTIONS #5 ABOVE)

The following materials are required to make Application for Licensure and/

or Examination in Illinois:

1. Four page APPLICATION FOR LICENSURE and /or EXAMINATION.

2. INSTRUCTION SHEET, which gives step by step application

instructions for your profession.

3. REFERENCE SHEET, which gives detailed coding information for

your profession.

4. SUPPORTING DOCUMENTS, forms, and/or any other documentation

you may be required to submit with your application.

5. If the name shown on your supporting documents is diﬀ erent from

that shown on your application, you must submit PROOF OF LEGAL

NAME change - copy of marriage license, divorce decree, aﬃ davit or

court order.

1. PROFESSION NAME

1. NAME LAST FIRST MIDDLE

8. PLACE OF BIRTH CITY STATE/COUNTRY

11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED

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.

IL486-1019 4/24 (LT)

3. LICENSURE METHOD

2. PROFESSION CODE

My application for this profession had previously been denied

in Illinois. I am reapplying since I have fulﬁ lled additional

requirements.

I have previously made application for this profession in

Illinois. However, I am now applying under new statutory

language.

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

Day Year

9. DATE OF BIRTH

Month

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

Carefully follow all steps outlined on the INSTRUCTION SHEET. In addition,

note the following:

A. Type or print legibly with black ink only.

B. FEES ARE NOT REFUNDABLE.

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

in accordance with 5 Illinois Compiled Statutes 100/10-65 to obtain a license.

The social security number may be provided to the Illinois Department of

Public Aid to identify persons who are more than 30 days delinquent in

complying with a child support order, or to the Illinois Department of Revenue

to identify persons who have 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 required by any tax Act administered by the Illinois Department

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

10. AGE

Female

Male

Work: ( __ __ __ ) __ __ __

__ __ __ __ Home: ( __ __ __ ) __ __ __

__ __ __ __

(Area Code) (Area Code)

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

12.

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov

7. MOTHER'S MAIDEN NAME

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.

Fax: ( __ __ __ ) __ __ __

__ __ __ __ Fax: ( __ __ __ ) __ __ __

__ __ __ __

(Area Code) (Area Code)

REQUIRED

E-MAIL ADDRESS

A. Check the box indicating the appropriate information regarding your application. Military Military Spouse Not Military Decline to Answer

Military service member is deﬁ ned as. “Service member means any person who, at the time of application under this Section, is an active duty member of the United

States Armed Forces or any reserve component of the United States Armed Forces, the Coast Guard, or the National Guard of any state, commonwealth, or territory

of the United States or the District of Columbia or whose active duty service concluded within the preceding 2 years before application.” The following will be

considered proof of you or your spouse’s active military status: DD214, Letter of Service signed by Unit Commanding Oﬃ cer, or Proof of Service document from the

Servicemember's electronic personnel portal. Proof for Spouses: Military Permanent Change of Station Orders with the spouse identiﬁ ed by name; Oﬃ cial

Notiﬁ cation of Change of Assignment with your marriage license, a certiﬁ ed DD1172 verifying marital status, or a letter signed by the commanding oﬃ cer verifying

change of assignment and the name of the military spouse.

Graduated Received

High School? Yes No OR G.E.D.? Yes No

1 2 3 4 5 6 7 8 9 10 11 12

Graduated? Yes No

LOCATION

(City and State or Country)

DATES OF ATTENDANCE

FROM TO

TYPE OF

DEGREE EARNED

6. COLLEGE OR UNIVERSITY NAME

(Undergraduate and Graduate)

Month/Year

DATES OF ATTENDANCE

FROM

LOCATION

(City and State or Country)

Yes No

Month/YearMonth/Year

Did You Complete

Training?

Month/Year

Month Year

4. DATE OF GRADUATION

PART III: Education Information

1. PRELIMINARY EDUCATION (Elementary and High School or G.E.D. Circle number of years completed)

INSTITUTION NAME

1 2 3 4 5 6 7 8

2. NAME OF LAST PRELIMINARY SCHOOL

ATTENDED

3. LAST PRELIMINARY SCHOOL LOCATION

(City and State)

5. COLLEGE OR UNIVERSITY (Circle number of years completed)

7. SPECIALIZED TRAINING (Residency, Professional Training, Vocational Training, Practical or Clinical Training)

IL486-1019

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 2 of 4

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

PART IV: Record of Licensure Information

IL486-1019

(If additional space is needed, attach a separate sheet.)

PROFESSION NAMESTATE

State of Current Licensure where you

most recently have been practicing.

Other States of Licensure

NAME OF EXAMINATION

(If additional space is needed, attach a separate sheet.)

PART V: Record of Examination

DATE OF

ISSUANCE

LICENSE NUMBER

LICENSE STATUS

(Active, Lapsed, etc.)

STATE

MONTH/YEAR EXAM RESULTS

(Passed, Failed, Absent)

If you have ever taken a licensure examination in Illinois or any other state for the profession for which you are now making

application, you must complete the information requested below. EACH EXAMINATION ATTEMPT MUST BE SHOWN.

Failure to disclose an examination attempt may result in the denial of your application or other appropriate action.

If you have ever been licensed to practice the profession for which you are now making application, or held a related license, complete

the information requested below. If you have ever held a temporary, trainee or apprenticeship license, or a permit, it must be listed here

also. In addition, the INSTRUCTION SHEET enclosed with this Application package may instruct you to have Certiﬁ cation(s) of Licen-

sure in other state(s) prepared and submitted in support of your application (contact other state(s) regarding possible fee). You must

also list all other licenses held in Illinois, however, certiﬁ cation of licensure from Illinois is not required. Failure to disclose all licenses

held may result in denial of your application or other appropriate action.

State of Original Licensure

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 3 of 4

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

PART VI: Personal History Information (This part must be completed by all applicants)

NOYES

Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me

in connection therewith, and to the best of my knowledge, they are true, correct, and complete. I UNDERSTAND THAT

FEES ARE NOT REFUNDABLE.

Signature of Applicant Date

PART IX: Certifying Statement

IL486-1019

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

PART VIII: Child Support, Tax Information and Workers' Compensation (Every applicant is required by law to

respond to the following questions)

PART VII: Examination Coding Information (This part is for examination applicants only)

Refer to the REFERENCE SHEET enclosed with this application package and complete the following:

a) CHART II - Select examination(s) you desire

and enter Test Codes

b) CHART III - Select the examination site you desire and enter Test Center Code:

c) CHART IV - Find your School of Graduation and enter school code:

d) Record the number of times you have taken this exam in Illinois or any other state:

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

1. In accordance with 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's

Social Security number, and the licensee shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying

with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to

contempt of court.

Are you more than 30 days delinquent in complying with a child support order? Yes No

(NOTE: If you are not subject to a child support order, answer "no.")

2. In accordance with 20 ILCS 2105-15(g), "The Department shall deny any license application or renewal authorized under any licensing Act

administered by the Department to any person who has failed to ﬁ le a return, or to pay the tax, penalty, or interest shown in a ﬁ led return, or to

pay any ﬁ nal assessment of tax, penalty, or interest, as required by any tax Act administered by the Illinois Department of Revenue, until such

time as the requirement of any such tax Act is satisﬁ ed."

Are you delinquent in the ﬁ ling of state taxes? Yes No

3. In accordance with 20 ILCS 2105/2105-15(g-5), “The Department shall refuse the issuance or renewal of a license to, or suspend or revoke

the license of, any individual, corporation, partnership, or other business entity that has been found by the Illinois Workers' Compensation

Commission or the Department of Insurance to have failed to secure workers' compensation obligations, or pay in full a ﬁ ne or penalty imposed

due to a failure to secure workers' compensation obligations.”

Are you delinquent in complying with workers’ compensation obligations? Yes No

1. Have you been convicted of or pled guilty or nolo contendere to any criminal oﬀ ense in any state or in federal court? Please do not give

details on minor traﬃ c charges, but do include information relating to Driving While Intoxicated (DWI) charges. If yes, attach a personal

statement describing the circumstances of the conviction and certiﬁ ed copies of court records of your conviction including the nature of

the oﬀ ense, date of discharge, and a statement from the probation or parole oﬃ ce. In general, a criminal conviction by itself does not

usually result in denial of licensure.

2. Have you been convicted of a felony? In general, a felony conviction by itself does not usually result in denial of licensure.

3. If yes, have you been issued a Certiﬁ cate of Relief from Disabilities by the Prisoner Review Board? If yes, attach a copy of the certiﬁ cate.

4. Do you now have any disease or condition that presently limits your ability to perform the essential functions of your profession, including

any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease or condition; (2)

alcohol or other substance abuse; (3) physical disease or condition? If yes, attach a detailed statement, including an explanation whether

or not you are currently under treatment.

5. Have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license or permit

disciplined in any way by any licensing authority in Illinois or elsewhere? If yes, attach a detailed explanation.

6. Have you ever been discharged other than honorably from the armed service or from a city, county, state or federal position? If yes, attach

a detailed explanation.

Pursuant to 20 ILCS 2105-165(a), the Department requires the following professionals to disclose information regarding charges or

convictions pertaining to certain oﬀ enses. Please check applicable profession.

Advanced Practice Registered Nurse

Acupuncturist

Audiologist

Dental Hygienist

Sex Oﬀ ender Evaluator

Dentist

Athletic Trainer

Genetic Counselor

Marriage and Family Therapist

Sex Oﬀ ender Associate

Licensed Practical Nurse

Psychologist, Clinical (LCP)

Professional Counselor, Clinical

(LCPC)

Registered Nurse

Sex Oﬀ ender Treatment Provider

Respiratory Care Practitioner

Podiatrist

Registered Surgical Assistant

Registered Surgical Technologist

Prosthetist

Advanced Practice Registered

Nurse - Full Practice Authority

Behavior Analyst

Behavior Analyst Assistant

Certiﬁ ed Midwife

Chiropractic Physicians (D.C.)

Professional Counselor (LPC)

Physician Assistant

Occupational Therapist

Occupational Therapy Assistant

Naprapath

Pharmacist

Physical Therapist

Physicians, including Medical

Doctors (M.D.), Doctors of

Osteopathic Medicine (D.O.)

Physical Therapy Assistant

Nursing Home Administrator

Orthotist

Pedorthist

Optometrist

Perfusionist

Social Worker, Clinical (LCSW)

Social Worker (LSW)

Speech Pathologist

IMPORTANT NOTICE: Completion of

this form is necessary to accomplish the

requirements outlined in 20 ILCS 2105 of

the Civil Administrative Code. Disclosure of

this information is REQUIRED.

HEALTH CARE WORKERS

ADDITIONAL PERSONAL HISTORY

QUESTIONS

SUPPORTING DOCUMENT

PHQ

1. NAME LAST FIRST MIDDLE

2. ADDRESS STREET, CITY, STATE, ZIP CODE

3. PROFESSIONAL LICENSE NUMBER (if any)

__ __ __ - __ __ __ __ __ __

4. SOCIAL SECURITY NUMBER OR ITIN

__ __ __ - __ __ - __ __ __ __

Certiﬁ cation Statement

Under penalties of perjury, I declare that I have examined this Form and all supporting documents and/or information

submitted by me in connection therewith, and to the best of my knowledge, they are true, correct, and complete.

In order for your application to be evaluated, you must respond to each of the following questions:

IL486-2034 12/23

Signature of Applicant Email Date

Page 1of 3

If YES to any of the above, attach a personal statement describing the circumstances of the charge or conviction and

a certiﬁ ed copy of the court records regarding your charge or conviction, including the nature of the oﬀ ense and date of

discharge, if applicable, as well as a statement from the probation or parole oﬃ ce.

Are you required, as part of a criminal sentence, to register under the Sex Oﬀ ender Registration Act? *

Are you currently charged with or have you been convicted of a criminal battery against any patient in the

course of patient care or treatment, including any oﬀ ense based on sexual conduct or sexual penetration?

Yes

Are you currently charged with or have you been convicted of a criminal act that requires registration

under the Sex Oﬀ ender Registration Act? *

Are you currently charged with or have you been convicted of a forcible felony? *

Marriage and Family Therapist Assoc.

Any other license issued by the Department under the Acts listed in this Section and the Controlled Substances Act [740 ILCS 40], except for pharmacy

technicians, issued to a person subject to the Code and this Part.

Music Therapist

IL486-2034 02/13 (crimacts)

Page 2 of 3

* DEFINITIONS

11-20.1 (child pornography),

11-20.3 (aggravated child pornography),

11-6 (indecent solicitation of a child),

11-9.1 (sexual exploitation of a child),

11-9.2 (custodial sexual misconduct),

11-9.5 (sexual misconduct with a person with a disability),

11-15.1 (soliciting for a juvenile prostitute),

11-18.1 (patronizing a juvenile prostitute),

11-17.1 (keeping a place of juvenile prostitution),

11-19.1 (juvenile pimping),

11-19.2 (exploitation of a child),

11-25 (grooming),

11-26 (traveling to meet a minor),

12-13 (criminal sexual assault),

12-14 (aggravated criminal sexual assault),

12-14.1 (predatory criminal sexual assault of a child),

12-15 (criminal sexual abuse),

12-16 (aggravated criminal sexual abuse),

12-33 (ritualized abuse of a child).

10-1 (kidnapping),

10-3 (unlawful restraint),

10-3.1 (aggravated unlawful restraint).

(1.6) First degree murder under Section 9-1 of the Criminal Code of 1961, when the victim was a person under 18 years of age and the

defendant was at least 17 years of age at the time of the commission of the oﬀ ense, provided the oﬀ ense was sexually motivated as

deﬁ ned in Section 10 of the Sex Oﬀ ender Management Board Act.

(1.7) (Blank).

(1.8) A violation or attempted violation of Section 11-11 (sexual relations within families) of the Criminal Code of 1961, and the oﬀ ense

was committed on or after June 1, 1997.

(1.9) Child abduction under paragraph (10) of subsection (b) of Section 105 of the Criminal Code of 1961 committed by luring or

attempting to lure a child under the age of 16 into a motor vehicle, building, house trailer, or dwelling place without the consent of the

parent or lawful custodian of the child for other than a lawful purpose and the oﬀ ense was committed on or after January 1, 1998,

provided the oﬀ ense was sexually motivated as deﬁ ned in Section 10 of the Sex Oﬀ ender Management Board Act.

(1.5) A violation of any of the following Sections of the Criminal Code of 1961, when the victim is a person under 18 years of age, the

defendant is not a parent of the victim, the oﬀ ense was sexually motivated as deﬁ ned in Section 10 of the Sex Oﬀ ender Management

Board Act, and the oﬀ ense was committed on or after January 1, 1996:

(1.10) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the oﬀ ense was committed on

or after July 1, 1999:

10-4 (forcible detention, if the victim is under 18 years of age), provided the oﬀ ense was sexually motivated as deﬁ ned

in Section 10 of the Sex Oﬀ ender Management Board Act,

11-6.5 (indecent solicitation of an adult),

11-15 (soliciting for a prostitute, if the victim is under 18 years of age),

11-16 (pandering, if the victim is under 18 years of age),

11-18 (patronizing a prostitute, if the victim is under 18 years of age),

11-19 (pimping, if the victim is under 18 years of age).

(1.11) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the oﬀ ense was committed on

or after August 22, 2002:

11-9 (public indecency for a third or subsequent conviction).

(1.12) A violation or attempted violation of Section 5.1 of the Wrongs to Children Act (permitting sexual abuse) when the oﬀ ense was

committed on or after August 22, 2002.

(2) A violation of any former law of this State substantially equivalent to any oﬀ ense listed in subsection (B) of this Section.

(C) A conviction for an oﬀ ense of federal law, Uniform Code of Military Justice, or the law of another state or a foreign country that is

substantially equivalent to any oﬀ ense listed in subsections (B), (C), (E), and (E5) of this Section shall constitute a conviction for the

purpose of this Article.

10-2 (aggravated kidnapping),

An attempt to commit any of these oﬀ enses.

730 ILCS 150 et. seq:—Acts that require Sex Oﬀ ender Registration:

(B) As used in this Article, “sex oﬀ ense” means:

(1) A violation of any of the following Sections of the Criminal Code of 1961:

* DEFINITIONS

A “forcible felony”, for the purposes of Section 2105-165 of the Code (section numbers are from

the Criminal Code of 1961 [720 ILCS 5]) and 68 Illinois Administrative Code 1130.120 is one or

more of the following oﬀ enses:

a) First Degree Murder (Section 9-1);

b) Intentional Homicide of an Unborn Child (Section 9-1.2);

c) Second Degree Murder (Section 9-2);

d) Voluntary Manslaughter of an Unborn Child (Section 9-2.1);

e) Drug-induced Homicide (Section 9-3.3);

f) Kidnapping (Section 10-1);

g) Aggravated Kidnapping (Section 10-2);

h) Unlawful Restraint (Section 10-3);

i) Aggravated Unlawful Restraint (Section 10-3.1);

j) Forcible Detention (Section 10-4);

k) Involuntary Servitude (Section 10-9(b));

l) Involuntary Sexual Servitude of a Minor (Section 10-9(c));

m) Traﬃ cking in Persons (Section 10-9(d));

n) Criminal Sexual Assault (Section 11-1.20);

o) Aggravated Criminal Sexual Assault (Section 11-1.30);

p) Predatory Criminal Sexual Assault of a Child (Section 11-1.40);

q) Criminal Sexual Abuse (Section 11-1.50);

r) Aggravated Criminal Sexual Abuse (Section 11-1.60);

s) Aggravated Battery (Section 12-3.05);

t) Compelling Organization Membership of Persons (Section 12-6.5);

u) Compelling Confession or Information by Force or Threat (Section 12-7);

v) Home Invasion (Section 12-11);

w) Robbery (Section 18-1);

x) Armed Robbery (Section 18-2);

y) Vehicular Hijacking (Section 18-3);

z) Aggravated Vehicular Hijacking (Section 18-4);

bb) Terrorism (Section 29D-14.9);

cc) Causing a Catastrophe (Section 29D-15.1);

dd) Possession of a Deadly Substance (Section 29D-15.2);

ee) Making a Terrorist Threat (Section 29D-20);

ﬀ ) Falsely Making a Terrorist Threat (Section 29D-25);

gg) Material Support for Terrorism (Section 29D-29.9);

hh) Hindering Prosecution of Terrorism (Section 29D-35);

ii) Boarding or Attempting to Board an Aircraft with Weapon (Section 29D-35.1);

jj) Armed Violence (Section 33A-2); and

kk) Attempt (Section 8-4) of any of the above speciﬁ ed oﬀ enses.

IL486-2034 02/13 (crimacts)

Page 3 of 3

aa) Aggravated Robbery (Section 18-5);

This page intentionally left blank

for double-sided printing.

RETURN COMPLETED FORM TO APPLICANT

LICENSING AGENCY: The Illinois Department of Financial and Professional Regulation will accept other forms

of certiﬁ cation provided all applicable information requested on this form is contained in

the certiﬁ cation. Please record N/A in areas which are not applicable.

PART I - CERTIFICATION OF EXAMINATION STATUS

A. The applicant has written is scheduled to write the following examination:

Date of ExaminationName of Examination

B. The applicant has or will have written the above-named examination _______ number of times.

PART II - CERTIFICATION OF LICENSURE

C. ISSUANCE DATE OF LICENSE

A. NAME OF PROFESSION AS IT APPEARS ON LICENSE

D. EXPIRATION DATE OF LICENSE

B. LICENSE NUMBER

E. LICENSURE METHOD

Examination (Administered in Your State)

National (Name) _____________________

State Constructed _____________________

Other (Name) _____________________

Endorsement of License (State) _____________________

Acceptance of Examination Results _____________________

(Administered in Another State)

F. CURRENT LICENSURE STATUS G. IF LICENSED BY EXAMINATION, RECORD SCORES

Active

Inactive

Lapsed

Other (Explain) ______________________________

___________________________________________

Type of Examination Score

Written ________

Practical ________

Other (Describe) ____________________

___________________________________

Received no Grade Below ________

Examination Period _____ days ______ hours

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.

SUPPORTING DOCUMENT

CERTIFICATION BY LICENSING

AGENCY / BOARD

APPLICANT: Complete the applicant section of this form then forward this form to the jurisdiction in which

you are requesting certiﬁ cation by a licensing agency/board. Contact certifying jurisdiction for

appropriate fee. You are authorized to photocopy this form as necessary.

3. SSN OR ITIN

Profession Name Profession Code

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 7. APPLICANT TELEPHONE NUMBER (Daytime)

2. DATE OF BIRTH

1. NAME LAST FIRST MIDDLE

__ __ __ - __ __ - __ __ __ __

8a. RECORD PROFESSION NAME AS IT APPEARS ON YOUR LICENSE

FROM THE JURISDICTION TO WHICH THIS FORM IS BEING FOR-

WARDED. (If applicable)

8b. LICENSE NUMBER (If appli-

cable)

8c. ISSUANCE DATE OF LICENSE

(If applicable)

I hereby authorize _________________________________________________ to furnish to the Illinois Department of

Financial and Professional Regulation or its designated testing service, the information requested below.

Signature _________________________________________ Date ______________________________________

Name of Licensing Agency or Board

Area Code ( ___ ___ ___ ) ___ ___ ___

___ ___ ___ ___

Reciprocity with (State) ________________

Waiver/Grandfather

Credentials

Other (Describe) ____________________

____________________________________

IL486-0850 12/23 (LT)

CT - Certiﬁ cation by Licensing Agency/Board - Page 1 of 2

Month Day Year

__ __ / __ __ / __ __ __ __

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 ___________________

PART III - CERTIFICATION OF EXAMINATION SCORES

SCORE

SCORESUBJECT DATE

SUBJECT DATE

DATESUBJECT

PART IV - FORMAL ACTIONS

A 2.

B. State Constructed Examination

I certify that the information contained herein is true and correct according to the oﬃ cial records of the State.

IL486-0850 (LT)

Print Name

City, State, ZIP Code

Title

Area Code ( )

Signature

Agency/Board Street Address

Date

Telephone Number

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.

S E A L

CT - Certiﬁ cation by Licensing Agency/Board - Page 2 of 2

Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT.

Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

Total academic years attended _____ _____ _____

Total calendar years attended _____ _____ _____

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.

SUPPORTING DOCUMENT

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

__ __ / __ __ / __ __ __ __

Month Day Year

__ __ __ - __ __ - __ __ __ __

2. DATE OF BIRTH

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

7. NAME OF INSTITUTION ATTENDED

Profession Name

Profession Code

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.

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

D. SPECIFIC PROGRAM OR CURRICULUM CONCENTRATION OF

APPLICANT

C. DEPARTMENT OF INSTITUTION

F. APPLICANT WAS (CHECK ONE):

E. MAJOR AREA OF STUDY OF THE APPLICANT

H. DATES OF ATTENDANCE

G. CREDIT HOURS EARNED

(CHECK ONE AND

COMPLETE)

IL486-1306 12/23 (LT)

K. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS WERE MET

M. CHECK THE APPROPRIATE STATEMENT(S) AND COMPLETE

L. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED

J. TYPE OF DEGREE OR CERTIFICATE AWARDED

(e.g., B.A., M.A., M.D., Ph.D.)

N. IF EDUCATION PROGRAM WAS COMPLETED IN LESS THAN THE NORMALLY REQUIRED TIME, PLEASE EXPLAIN:

From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __

__ __ /__ __ /__ __ __ __

Full-time Part-time Co-op

_________ Semester Hours

_________ Quarter Hours

_________ Course Hours

CERTIFICATION OF EDUCATION

3. SSN OR ITIN

Date Signature of Applicant

Month Day Year

__ __ /__ __ /__ __ __ __

Applicant has completed program on __ __ / __ __ / __ __ __ __

Applicant will complete program on __ __ / __ __ / __ __ __ __

Applicant has graduated on __ __ /__ __ /__ __ __ __

Applicant will graduate on __ __ /__ __ /__ __ __ __

Month Day Year

ED - Certiﬁ cation of Education - Page 1 of 2

Month Day Year

Month Day Year Month Day Year

Years Months Days

I certify that the information recorded herein is true and correct according to the oﬃ cial records of this institution.

Title Date

Print Name of School Oﬃ cial Signature of School Oﬃ cial

NOTE: If the institution does not have a school seal, this form must be notarized.

Subscribed and sworn before me this _____ day of _______________ , 20____.

Date of Expiration Signature of Notary Public

SCHOOL OFFICIAL: RETURN THIS FORM TO APPLICANT

IL486-1306 (LT)

O. USE THIS SPACE TO RECORD ANY OTHER INFORMATION THAT YOU FEEL WOULD ASSIST THE DEPARTMENT IN EVALUATING

THE APPLICANT'S EDUCATIONAL EXPERIENCES.

ATTENTION APPLICANT: FOR INCLUSION WITH THE APPLICATION PACKET.

ED - Certiﬁ cation of Education - Page 2 of 2

SCHOOL SEAL OR NOTARY SEAL

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

IMPORTANT NOTICE: Completion of

this form is necessary to accomplish the

requirements outlined in 225 of the Illinois

Compiled Statutes. Disclosure of this

information is VOLUNTARY. However,

failure to comply may result in this form not

being processed.

VERIFICATION OF

EMPLOYMENT / EXPERIENCE

SUPPORTING DOCUMENT

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.

1. NAME LAST FIRST MIDDLE

6. MAIDEN OR GIVEN SURNAME

4. ADDRESS STREET, CITY, STATE, ZIP CODE

8. DATES OF EMPLOYMENT

From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __

Month Day Year Month Day Year

2. DATE OF BIRTH

3. SSN OR ITIN

5. REFER TO REFERENCE SHEET. Record profession name and

three digit profession code for which you are making Illinois application.

7. JOB TITLE OR POSITION APPLICANT HELD

9. SUPERVISOR NAME

___ ___ ___

Profession Name Profession Code

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

C. EMPLOYER REGISTRATION/LI-

CENSE NUMBER

F. BUSINESS REGISTRATION/LI-

CENSE NUMBER (If Applicable)

PART II - APPLICANT EMPLOYMENT INFORMATION

A. NUMBER OF HOURS WORKED

PER WEEK

B. BUSINESS / INSTITUTION NAME

E. BUSINESS ADDRESS STREET CITY STATE ZIP CODE

H. BUSINESS TELEPHONE NUMBER

C. DATES OF EMPLOYMENT

G. STATE OF BUSINESS

REGISTRATION/LICENSE

D. STATE OF EMPLOYER

REGISTRATION/LICENSE

B. TYPE OF EMPLOYMENT

Area Code (___ ___ ___) ___ ___ ___

___ ___ ___ ___

[ ]Full-time [ ]Part-time

E. GIVE BRIEF DESCRIPTION OF DUTIES PERFORMED BY THE APPLICANT.

D. RECORD APPLICANT'S POSITION TITLE(S)

I do hereby declare that this information is true and correct.

Signature

TitleDate

IL486-1348 1/24 (L&T)

__ __ __ - __ __ - __ __ __ __

Month Day Year

__ __ / __ __ / __ __ __ __

From __ __ /__ __ /__ __ __ __ To __ __ /__ __ /__ __ __ __

Month Day Year Month Day Year

CERTIFYING OFFICIAL: Complete the remainder of this form. RETURN THE COMPLETED APPLICATION TO

THE APPLICANT.

TN-D-OPT

VERIFICATION OF DIAGNOSTIC

TRAINING

APPLICANT: Complete the applicant section of this form. Forward form to the individual who will certify your

training.

Yes No

1. NAME LAST FIRST MIDDLE

7. DATES OF TRAINING

6. MAIDEN OR GIVEN SURNAME

4. ADDRESS STREET, CITY, STATE, ZIP CODE

8. COURSE TITLE / INSTITUTION

Profession Name

3. SSN OR ITIN

5. REFER TO REFERENCE SHEET. Record profession name and three

digit profession code for which you are making Illinois application.

Profession Code

SUPPORTING DOCUMENT

A. CERTIFYING OFFICIAL

C. INSTRUCTOR JOB TITLE/PROFESSION NAME

E. INSTITUTION TELEPHONE NUMBER

G. APPLICANT'S TRAINING DATES

I. DID APPLICANT SUCCESSFULLY COMPLETE TRAINING COURSE?

B. INSTITUTION NAME

D. INSTITUTION STREET ADDRESS

F. INSTITUTION CITY, STATE, ZIP CODE

H. TRAINING CLOCK HOURS APPLICANT

J. IF TRAINING WAS OBTAINED OUTSIDE OF AN INSTITUTION FACILITY, INDICATE THE SETTING(S) IN WHICH TRAINING WAS OB-

TAINED.

IL486-1752 1/24 (LT-A)

__ __ __ - __ __ - __ __ __ __

__ __ / __ __ / __ __ __ __

Month Day Year

2. DATE OF BIRTH

From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __

Month Day Year

From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __

Month Day Year

OPTOMETRY

0 4 6

TN-D-OPT - Page 1 of 2

Area Code ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

IMPORTANT NOTICE: Completion of this form is

necessary to accomplish the requirements outlined

in 225 ILCS 80 et.seq. (Illinois Compiled Statutes).

Disclosure of this information is VOLUNTARY. How-

ever, failure to comply may result in this form not

being processed.

IL486-1752 (LT-B)

I certify that the information recorded herein is true and correct according to the oﬃ cial records of this institution.

ATTENTION APPLICANT: FOR INCLUSION WITH THE APPLICATION PACKET.

K. RECORD ANY ADDITIONAL COMMENTS YOU WISH TO MAKE REGARDING THE APPLICANT'S TRAINING.

Print Name of School Oﬃ cial

Title

Signature of School Oﬃ cial and/or Director/Administrator

of Training Programs

Date

TN-D-OPT - Page 2 of 2

NOTE: If the institution does not have a school seal, this form must be notarized.

Subscribed and sworn before me this _____ day of _______________ , 20____.

Date of Expiration Signature of Notary Public

SCHOOL SEAL OR NOTARY SEAL

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

CERTIFYING OFFICIAL: Complete the remainder of this form. RETURN COMPLETED FORM TO APPLICANT.

APPLICANT: Complete the applicant section of this form. Forward the form to the individual who will certify your

training. This form must be completed for individuals graduating after January 1, 1994.

1. NAME LAST FIRST MIDDLE

7. DATES OF TRAINING

6. MAIDEN OR GIVEN SURNAME

4. ADDRESS STREET, CITY, STATE, ZIP CODE

8. COURSE TITLE / INSTITUTION

Profession Name

3. SSN OR ITIN

2. DATE OF BIRTH

5. REFER TO REFERENCE SHEET. Record profession name and three

digit profession code for which you are making Illinois application.

Profession Code

SUPPORTING DOCUMENT

Yes No

A. CERTIFYING OFFICIAL

C. INSTRUCTOR JOB TITLE/PROFESSION NAME

E. INSTITUTION TELEPHONE NUMBER

G. APPLICANT’S TRAINING DATES

I. DID APPLICANT SUCCESSFULLY COMPLETE TRAINING COURSE?

B. INSTITUTION NAME

D. INSTITUTION STREET ADDRESS

F. INSTITUTION CITY, STATE, ZIP CODE

H. TRAINING CLOCK HOURS APPLICANT

J. IF TRAINING WAS OBTAINED OUTSIDE OF AN INSTITUTION FACILITY, INDICATE THE SETTING(S) IN WHICH TRAINING WAS OB-

TAINED.

IL486-1753 1/24 (OP)

TN-T-

ORALS

VERIFICATION OF ORAL

THERAPEUTIC TRAINING

__ __ /__ __ /__ __ __ __

__ __ __-__ __-__ __ __ __

From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __

From __ __/__ __/__ __ __ __ To __ __/__ __/__ __ __ __

TN-T-OPT 30 HOURS - Page 1 of 2

Month Day Year

Month Day Year Month Day Year

OPTOMETRY

0 4 6

Month Day Year Month Day Year

Area Code ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

IMPORTANT NOTICE: Completion of this form is

necessary to accomplish the requirements outlined

in 225 ILCS 80 et.seq. (Illinois Compiled Statutes).

Disclosure of this information is VOLUNTARY. How-

ever, failure to comply may result in this form not

being processed.

IL486-1753 (OP)

I certify that the information recorded herein is true and correct according to the oﬃ cial records of this institution.

Print Name of School Oﬃ cial

Title

Signature of Chief Academic Oﬃ cer

Date

I certify that this applicant for Illinois licensure has successfully completed 30 hours of

therapeutic ocular training in systemic disease. The subject areas were:

Name of Instructor

a. Cardiovascular ___________________________________

b. Respiratory Disorders (e.g. Pulmonary) ___________________________________

c. Immunology ___________________________________

d. Infectious Disease ___________________________________

e. Dermatology ___________________________________

f. Cataract Surgery - 2 hours maximum ___________________________________

g. General Medical Emergency ___________________________________

h. Endocrinology ___________________________________

i. Collagen Vascular Disease _____________________________________

TN-T-OPT 30 HOURS - Page 2 of 2

NOTE: If the institution does not have a school seal, this form must be notarized.

Subscribed and sworn before me this _____ day of _______________ , 20____.

Date of Expiration Signature of Notary Public

SCHOOL SEAL OR NOTARY SEAL

ATTENTION APPLICANT: FOR INCLUSION WITH THE APPLICATION PACKET.

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

CERTIFYING OFFICIAL: Complete the remainder of this form. RETURN THE COMPLETED FORM TO THE

APPLICANT.

TN-T-OPT

120 Hours

VERIFICATION OF 120 HOURS OF

THERAPEUTIC TRAINING

APPLICANT: Complete the applicant section of this form. Forward form to the individual who will certify your

training. Training must have been obtained after January 1, 1994.

Yes No

1. NAME LAST FIRST MIDDLE

7. DATES OF TRAINING

6. MAIDEN OR GIVEN SURNAME

4. ADDRESS STREET, CITY, STATE, ZIP CODE

8. COURSE TITLE / INSTITUTION

Profession Name

3. SSN OR ITIN

5. REFER TO REFERENCE SHEET. Record profession name and three

digit profession code for which you are making Illinois application.

Profession Code

SUPPORTING DOCUMENT

A. CERTIFYING OFFICIAL

C. INSTRUCTOR JOB TITLE/PROFESSION NAME

E. INSTITUTION TELEPHONE NUMBER

G. APPLICANT'S TRAINING DATES

I. DID APPLICANT SUCCESSFULLY COMPLETE TRAINING COURSE?

B. INSTITUTION NAME

D. INSTITUTION STREET ADDRESS

F. INSTITUTION CITY, STATE, ZIP CODE

H. TRAINING CLOCK HOURS APPLICANT

J. IF TRAINING WAS OBTAINED OUTSIDE OF AN INSTITUTION FACILITY, INDICATE THE SETTING(S) IN WHICH TRAINING WAS OB-

TAINED.

IL486-1774 1/24 (OP)

__ __ __ - __ __ - __ __ __ __

__ __ / __ __ / __ __ __ __

Month Day Year

2. DATE OF BIRTH

From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __

Month Day Year

From __ __ / __ __ / __ __ __ __ To __ __ / __ __ / __ __ __ __

Month Day Year

OPTOMETRY

0 4 6

TN-T-OPT 120 HOURS - Page 1 of 2

Area Code ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

IMPORTANT NOTICE: Completion of this form is

necessary to accomplish the requirements outlined

in 225 ILCS 80 et.seq. (Illinois Compiled Statutes).

Disclosure of this information is VOLUNTARY. How-

ever, failure to comply may result in this form not

being processed.

I certify that the information recorded herein is true and correct according to the oﬃ cial records of this institution.

K. RECORD ANY ADDITIONAL COMMENTS YOU WISH TO MAKE REGARDING THE APPLICANT'S TRAINING.

Print Name of School Oﬃ cial

Title

Signature of Chief Academic Oﬃ cer

Date

IL486-1774 (OP)

TN-T-OPT 120 HOURS - Page 2 of 2

I. At least 60 hours taught by faculty members of the college or university sponsoring the course in the following subject areas:

1. Anatomy and Physiology Considerations in Ocular Disease - 5 hours minimum

2. Pharmacology of Therapeutic Agents - 10 hours minimum

3. Speciﬁ c Ocular Disease Considerations - 15 hours minimum

a. Bacterial

b. Viral and Chlamydial

c. Allergic

d. Fungal

e. Clinical Diagnosis and Treatment of Anterior Uveitis

f. Clinical Diagnosis and Management of Posterior Uveitis

g. Lacrimal Disorders

II. Other Ocular Diseases/Disorders - 15 hours minimum

a. Pre-Post Operative Cataract Care

b. Integration of Nervous System Assessment and Neuro-Ophthalmic Disorders

c. Practical Management of Ocular Emergencies

d. Diabetic Complications - Diabetic Retinopathy

e. Sudden Vision Loss

III. Glaucoma Diagnosis, Treatment and Management - 10 hours minimum

a. Pathophysiology of Glaucoma

b. Open Angle Glaucoma

c. Angle Closure Glaucoma

IV. Clinical Laboratory Tests and Services - 3 hours minimum

At least 30 hours of Clinical Medical Perspectives/Primary Care Medicine for the Ophthalmic Practitioner that

shall be taught by medical faculty members. The 30 hours shall be in the following areas:

a. Cardiovascular

b. Respiratory Disorders (e.g. Pulmonary)

c. Immunology

d. Infectious Disease

e. Dermatology

f. Cataract Surgery - 2 hours maximum

g. General Medical Emergency

h. Endocrinology

i. Collagen Vascular Disease

NOTE: If the institution does not have a school seal, this form must be notarized.

Subscribed and sworn before me this _____ day of _______________ , 20____.

Date of Expiration Signature of Notary Public

SCHOOL SEAL OR NOTARY SEAL

ATTENTION APPLICANT: FOR INCLUSION WITH THE APPLICATION PACKET.

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

If you hold a non-renewed controlled substances registration, you must

reinstate that registration. Do not apply for a new registration.

Every person who prescribes and/or stores or dispenses any controlled substances within the State of Illinois

must obtain a license issued by the Department of Financial and Professional Regulation in accordance with

the Illinois Controlled Substances Act.

A separate controlled substances registration is required for each place of professional practice or business where

controlled substances are stored or dispensed.

1. If you do not properly complete Parts I through VII (front and back) of the application, the application

will be returned to you and licensure will be delayed.

2. It is mandatory that the permanent mailing address and/or business address be a street address. P.O. boxes

are not acceptable. Your Controlled Substances registration must be issued to a street address.

3. If your professional application is pending, write "pending" in Part IV. A controlled substances registration

will not be issued until your professional license has been issued. A controlled substances registration will

not be issued to individuals holding a temporary license.

4. You must circle each drug schedule for which you are applying in Part III.

5. You must complete and submit the PHQ Form. Your application will not be processed without completion

of this form.

6. Fee payment of $5, in the form of check or money order made payable to the Illinois Department of

Financial and Professional Regulation (IDFPR) or payment online by visiting https://idfpr.illinois.gov/epay.

html. The fee is non-refundable. Forward two-page application, supporting documentation, and check or

money order (if payment is not being made online at https://idfpr.illinois.gov/epay.html), to:

Department of Financial and Professional Regulation

ATTN: Division of Professional Regulation

P.O. Box 7007

Springﬁ eld, Illinois 62791

A State controlled substances registration is a prerequisite for Federal controlled substances registration. The

address on your Illinois controlled substances registration must be exactly the same address as your Federal

registration. For information concerning Federal registration, you must contact:

Drug Enforcement Administration

230 South Dearborn, Suite 1200

Chicago, Illinois 60604

Telephone: 312/353-7875

Web site: www.deadiversion.usdoj.gov

INSTRUCTIONS FOR CONTROLLED SUBSTANCES REGISTRATION

IL486-0500 5/24 (LT-INS)

****READ AND FOLLOW INSTRUCTIONS CAREFULLY****

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov.

319 Dentist 346 Optometrist

316 Podiatrist 390 Veterinarian

336 Physician 377 APRN-FPA

Work ( )

Home ( )

PART I: Application Category Information

Registration

2. PROFESSION CODE - Check applicable box

1. PROFESSION NAME

3. LICENSURE METHOD

Controlled Substances

4. FEE

Disclosure of your U.S. social security number, if you have one, is mandatory, in accordance with 5 Illinois Compiled

Statutes 100/10-65 to obtain a license. The social security number may be provided to the Illinois Department of

Public Aid to identify persons who are more than 30 days delinquent in complying with a child support order, or

to the Illinois Department of Revenue to identify persons who have 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 required by any tax

Act administered by the Illinois Department of Revenue, or to other entities for veriﬁ cation of identiﬁ cation.

APPLICATION FOR STATE

CONTROLLED SUBSTANCES REGISTRATION

PART II: Applicant Identifying Information

1. NAME LAST FIRST MIDDLE

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

4. PERMANENT MAILING ADDRESS CITY STATE/COUNTRY ZIP CODE COUNTY

IL486-0500

5. NAME OF BUSINESS AND LOCATION (STREET / CITY / STATE / ZIP CODE) WHERE DRUGS ARE STORED AND CONTROLLED

SUBSTANCES REGISTRATION IS TO BE ISSUED

PART IV: Professional Activity

Area Code

9. TELEPHONE NUMBER WHERE YOU MAY BE REACHED DURING THE DAY

8. MAIDEN OR GIVEN SURNAME, OR ANY NAME(S)

3. SSN OR ITIN

Application for State Controlled Substances Registration - Page 1 of 2

FAX ( )

Area Code

IMPORTANT NOTICE: Completion of this form is required by 720 ILCS 570/1 et. seq. (Illinois

Compiled Statutes). Disclosure of information is mandatory. Furnishing by applicant of false or

fraudulent information or failure to provide pertinent information constitutes grounds for denying

such application or revoking any registration issued pursuant to such application.

FOR OFFICIAL USE ONLY

PART III: Drug Schedule

Dentist 019 - ___________________

Optometrist 046 - ___________________

Physician 036 - ___________________

Podiatrist 016 - ___________________

Veterinarian 090 - ___________________

APN-FP 277 - ___________________

Practitioner--Check and complete one of the following:

Professional License Number

II III IV V

Circle the schedules for which you are applying:

I will not be storing or dispensing controlled

substances, including samples.

7. If you will not be storing or dispensing controlled

substances, check the box below. Your license will

be issued to your permanent mailing address.

6. EMAIL ADDRESS (REQUIRED)

1. Have you been convicted of or pled guilty or nolo contendere to any criminal oﬀ ense in any state or in federal court? Please

do not give details on minor traﬃ c charges, but do include information relating to Driving While Intoxicated (DWI) charges.

If yes, attach a personal statement describing the circumstances of the conviction and certiﬁ ed copies of court records of

your conviction including the nature of the oﬀ ense, date of discharge, and a statement from the probation or parole oﬃ ce.

In general, a criminal conviction by itself does not usually result in denial of licensure.

2. Have you been convicted of a felony? In general, a felony conviction by itself does not usually result in denial of licensure.

3. If yes, have you been issued a Certiﬁ cate of Relief from Disabilities by the Prisoner Review Board? If yes, attach a copy

of the certiﬁ cate.

4. Do you now have any disease or condition that presently limits your ability to perform the essential functions of your pro-

fession, including any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or

emotional disease or condition; (2) alcohol or other substance abuse; (3) physical disease or condition? If yes, attach a

detailed statement, including an explanation whether or not you are currently under treatment.

5. Have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license

or permit disciplined in any way by any licensing authority in Illinois or elsewhere? If yes, attach a detailed explanation.

6. Have you ever been discharged other than honorably from the armed service or from a city, county, state or federal position?

If yes, attach a detailed explanation.

7. Has your authority to prescribe or dispense controlled substances granted by either the U.S. Drug Enforcement Admin-

istration (DEA) or any state/territory of the U.S. (including Illinois) ever been voluntarily or involuntarily reduced, limited,

placed on probation, relinquished, denied, revoked or suspended or otherwise disciplined? You must answer yes if any of

the above actions are currently pending or if you have withdrawn or failed to proceed with an application for any controlled

substances license. If yes, attach a separate sheet with complete and accurate explanation and certiﬁ ed documentation

from the appropriate entity regarding the action.

PART V: Personal History Information (This part must be completed by all Applicants) YES NO

IL486-0500

Application for State Controlled Substances Registration - Page 2 of 2

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

PART VII: Method of Payment and Certifying Statement

PART VI: Child Support, Tax Information and Workers' Compensation (Every applicant is required by law to

respond to the following questions)

1. In accordance with 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's

Social Security number, and the licensee shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying

with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to

contempt of court.

Are you more than 30 days delinquent in complying with a child support order? Yes No

(NOTE: If you are not subject to a child support order, answer "no.")

2. In accordance with 20 ILCS 2105-15(g), "The Department shall deny any license application or renewal authorized under any licensing Act

administered by the Department to any person who has failed to ﬁ le a return, or to pay the tax, penalty, or interest shown in a ﬁ led return, or to

pay any ﬁ nal assessment of tax, penalty, or interest, as required by any tax Act administered by the Illinois Department of Revenue, until such

time as the requirement of any such tax Act is satisﬁ ed."

Are you delinquent in the ﬁ ling of state taxes? Yes No

3. In accordance with 20 ILCS 2105/2105-15(g-5), “The Department shall refuse the issuance or renewal of a license to, or suspend or revoke

the license of, any individual, corporation, partnership, or other business entity that has been found by the Illinois Workers' Compensation

Commission or the Department of Insurance to have failed to secure workers' compensation obligations, or pay in full a ﬁ ne or penalty imposed

due to a failure to secure workers' compensation obligations.”

Are you delinquent in complying with workers’ compensation obligations? Yes No

Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connection therewith, and to

the best of my knowledge, they are true, correct, and complete. I UNDERSTAND THAT FEES ARE NOT REFUNDABLE.

Signature of Applicant Date

Check / Money Order. Check Number: _____________

Online. Paid Online at:https://idfpr.illinois.gov/epay.html in the amount of ______________. Approved #:______________