APRN-FPA.indd

Packet Revised on 5/29/24

INSTRUCTION / INFORMATION SHEET

ADVANCED PRACTICE REGISTERED NURSE -

FULL PRACTICE AUTHORITY (Profession Code - 277)

DPR APRN-FPA Instructions Revised 12/23

The Illinois Nurse Practice Act and Rules and additional application forms for Advanced

Practice Registered Nurse Licensure and for the Controlled Substance License can be

downloaded from the IDFPR Web site at: www.idfpr.illinois.gov

Certiﬁ ed Nurse Midwife Certiﬁ ed Clinical Nurse Specialist

Certiﬁ ed Nurse Practitioner

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.

Before completing the application package, please read the following.

APPLICATION FOR ADVANCED PRACTICE REGISTERED NURSE FULL PRACTICE AUTHORITY LICENSURE

 Part I, Box 5, page 1 - Specify the category of advanced practice nursing for which your are applying. A separate

fee and application is required for each category.

 Part I, Box 6, page 1 - Indicate your current Illinois Registered Nurse License Number and Illinois APRN License Number.

 Part II-V, pages 1 and 2 - Complete all applicable information requested in pages 1 and 2.

APRN-FPA LICENSURE REQUIREMENTS

 Speciﬁ c instructions for each category of advanced practice registered nursing for which you are applying are located on the

following pages.

 Locate the instructions for speciﬁ c category you selected in Part 1, Box 5 of the Application for Advanced Practice

Nurse Licensure and follow those instructions only.

ASSISTANCE IN COMPLETING APPLICATIONS

 If you need assistance in completing the application, you may call 1-800-560-6420 or (TTY) 1-866-325-4949. Inform the operator

that you are applying for Advanced Practice Registered Nurse - Full Practice Authority Licensure and that you would like assis-

tance in completing your application.

APPLICATION FEE

 The APRN-FPA application fee is $125. A separate fee and application are required for each category of licensure. The

fee payment must be in the form of a check or money order made payable to the Department of Financial and Profes-

sional Regulation. THIS FEE IS NOT REFUNDABLE.

SUBMISSION OF APPLICATION

 The two-page application, supporting documents and fee payment should be forwarded as a complete packet to:

Illinois Department of Financial and Professional Regulation

ATTN: Division of Professional Regulation

P.O. Box 7007

Springﬁ eld, Illinois 62791

APPLICATION LICENSURE EXPIRATION

 The application, which you submit, is valid for three (3) years from the date of receipt.

 All Illinois Advanced Practice Registered Nurse - Full Practice Authority licenses will expire on May 31 of every

even-numbered year.

Note: A CURRENT ILLINOIS REGISTERED NURSE LICENSE AND A CURRENT ILLINOIS ADVANCED

PRACTICE REGISTERED NURSE LICENSE ARE REQUIRED FOR FULL PRACTICE AUTHORITY.

NOTES:

 Upon issuance of an APRN license with Full Practice Authority, the regular APRN license will go inactive.

 Prior to prescribing as an APRN granted Full Practice Authority, the APRN must apply for a practitioner license under the

Illinois Controlled Substances Act.

Submit the following documents and/or forms with the two-page application and fee:

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

processed without completion of this form.

2. A current copy of your national certiﬁ cation (certiﬁ cation or pocket card accepted) from one of the following:

 American Academy of Nurse Practitioners Certiﬁ cation Program as a Nurse Practitioner

 American Nurses Credentialing Center as a Nurse Practitioner

 The Pediatric Nurse Certiﬁ cation Board as a Nurse Practitioner

 The National Certiﬁ cation Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties as a

Nurse Practitioner

 The Certiﬁ cation Board for Urologic Nurses and Associates as a Urologic Nurse Practitioner.

3. Aﬃ davit certifying 250 hours of additional Continuing Education (CE) or training.

4. Supporting Document VE-APRN-FPA must be completed indicating 4000 hours of clinical experience.

CERTIFIED NURSE PRACTITIONER

Advanced Practice Nurse License - Page 2

Submit the following documents and/or forms with the two-page application and fee:

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

processed without completion of this form.

2. A current copy of your national certiﬁ cation (certiﬁ cation or pocket card accepted) from one of the following:

 The American College of Nurse Midwives (ACNM); OR

 The American College of Nurse Midwives Certiﬁ cation Council (ACC)

3. Aﬃ davit certifying 250 hours of additional Continuing Education (CE) or training.

4. Supporting Document VE-APRN-FPA must be completed indicating 4000 hours of clinical experience.

CERTIFIED NURSE MIDWIFE

Submit the following documents and/or forms with the two-page application and fee:

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

processed without completion of this form.

2. A current copy of your national certiﬁ cation (certiﬁ cation or pocket card accepted) from one of the following:

 American Nurses Credentialing Center (ANCC)

Clinical Nurse Specialist Psychiatric and Mental Health Nursing

Clinical Specialists in Community Health Nursing Cardiac and Vascular Nurse

Clinical Specialists in Gerontology Nursing College Health Nurse

Clinical Specialists in Home Health Nursing Perinatal Nurse

Clinical Specialists in Pediatric Nursing Ambulatory Care Nursing

Clinical Specialists in Psychiatric and Mental Health Nursing - Adults Diabetes

Clinical Specialists in Psychiatric and Mental Health Nursing - Adolescent

 American Association of Critical Care Nurses as a Clinical Nurse Specialist

 Rehabilitation Nursing Certiﬁ cation Board as a Certiﬁ ed Rehabilitation Registered Nurse--Advanced

 Oncology Nursing Certiﬁ cation Corporation as an Advanced Oncology Certiﬁ ed Nurse (AOCN)

 Certiﬁ cation Board for Urologic Nurses and Associates as a Urologic Clinical Nurse Specialist.

 American College of Cardiovascular Nursing

 American Association of Critical Care Nurses

 American Association of Neuroscience Nurses

 American Board of Occupational Health Nurses, Inc.

 American Holistic Nurses Association

 American Society of Perianesthesia Nurses

 American Society of Plastic Reconstructive Surgical Nurses

 Association of Nurses in AIDS Care

 Board of Certiﬁ cation of Emergency Nurses

 Certiﬁ cation Board of Perioperative Nurses, Inc.

 Certiﬁ cation of Pediatric Oncology Nurses

 Certiﬁ cation Board of Gastroenterology Nurses

 Dermatology Certiﬁ cation Board

 International Board of Lactation Consultants

 International Nurses Society of Addictions

 IV Nurses Certiﬁ cation Corporation

 National Association of School Nurses, Inc.

 National Board of Certiﬁ cation of Hospice and Palliative Nurses

 National Certiﬁ cation Board for Diabetes Educators

 National Certiﬁ cation Board of Pediatric Nurse Practitioners/Nurses

 National Certiﬁ cation Corporation for the Obstetric, Gynecological and Neonatal Nursing Specialties

 National Certifying Board for Ophthalmic Registered Nurses

 Nephrology Nursing Certiﬁ cation Board

 Oncology Nursing Certiﬁ cation Corporation

 Orthopedic Nurses Certiﬁ cation Board

Rehabilitation Nursing Certiﬁ cation Board

 Vascular Nursing Certiﬁ cation Board

 Wound, Ostomy, and Continence Society

3. Aﬃ davit certifying 250 hours of additional Continuing Education (CE) or training.

4. Supporting Document VE-APRN-FPA must be completed indicating 4000 hours of clinical experience.

Advanced Practice Nurse License - Page 3

CERTIFIED CLINICAL NURSE SPECIALIST

Advanced Practice Nurse License - Page 4

Applicants seeking licensure in more than one advanced practice nursing category may apply for licenses for multiple advanced practice

nurse licensure categories if the applicant has met the requirements for at least one advanced practice nursing specialty; and

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

without completion of this form.

2. Submits proof in the form of oﬃ cial transcripts with the school seal aﬃ xed that he/she possesses an additional graduate

education that results in a certiﬁ cate for another clinical advanced practice nurse category and that meets the requirements for

the national certiﬁ cation from the appropriate nursing specialty; and

3. He/she submits a copy of a current, national certiﬁ cation from the appropriate certifying body for that additional advanced

practice nursing category.

SPECIAL INSTRUCTIONS FOR APPLICANTS SEEKING LICENSURE IN

MORE THAN ONE ADVANCED PRACTICE NURSING CATEGORY

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

Illinois Department of Financial and Professional Regulation

Division of Professional Regulation

Application Checklist for Advanced Practice Registered Nurse - Full Practice Authority

IL486-1971 (APRN-FPA) 12/23

Before you submit your application, check the following items to make sure your application is complete!

All supporting documents may not be required. Please refer to application instructions

for your speciﬁ c method of licensure.

SUBMITTED

In order for your application to be processed,

ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE UPLOADED

to the portal with required fee unless otherwise directed in the instructions.

SUPPORTING DOCUMENTS

Application Fee--$125;

CURRENT COPY OF NATIONAL CERTIFICATION

VE APRN-FPA form must indicate 4000 hours of clinical experience

AFFIDAVIT certifying the completion of 250 additional Continuing Education or

Training

PART I: Application Category Information

2. PROFESSION CODE

1. PROFESSION NAME 3. LICENSURE METHOD

Advanced Practice Registered Nurse -

Full Practice Authority

$125

4. FEE

A. Type or print legibly with black ink only.

B. The fee is $125 - Make check payable to the Department of Financial and Professional

Regulation. THIS FEE IS NOT REFUNDABLE! (Separate application/fee is required

for each category of APN licensure.)

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. 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 ADVANCED PRACTICE REGISTERED NURSE -

FULL PRACTICE AUTHORITY LICENSURE

A CURRENT ILLINOIS REGISTERED NURSE LICENSE IS REQUIRED FOR

ADVANCED PRACTICE REGISTERED NURSE - FULL PRACTICE AUTHORITY LICENSURE

PART II: Applicant Identifying Information

1. NAME LAST FIRST MIDDLE

2. TITLE (e.g., APN Specialty)

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

5. MAIDEN, GIVEN, OR OTHER USED NAME(S)

3. SSN or ITIN

(DO NOT USE THIS APPLICATION FOR RENEWAL OF AN EXISTING LICENSE)

Application for Advanced Practice Registered Nurse License - Page 1 of 2

IMPORTANT NOTICE: Completion of this form

is necessary for consideration for licensure

under 225 ilcs 65/1 et. seq. (Illinois Compiled

Statutes). Disclosure of this information is

VOLUNTARY. However, failure to comply may

result in this form not being processed.

The following materials are required to make application for an

Advanced Practice Nursing license in Illinois:

1. APPLICATION FOR ADVANCED PRACTICE NURSE LICEN-

SURE.

2. SUPPORTING DOCUMENTS, forms, and/or any other

documentation you may be required to submit with your

application.

3. 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.

 Certiﬁ ed Clinical Nurse Specialist Certiﬁ ed Nurse Practitioner

 Certiﬁ ed Nurse Midwife

277

6. INDICATE YOUR CURRENT ILLINOIS

REGISTERED NURSE AND APRN

LICENSE NUMBERS:

5. CHECK ONE OF THE FOLLOWING BOXES INDICATING THE CATEGORY OF ADVANCED

PRACTICE NURSE:

041-

209 -

6. PLACE OF BIRTH

(CITY, STATE/COUNTRY)

9. TELEPHONE NUMBER WHERE YOU MAY BE REACHED

Day Year

7. DATE OF BIRTH 8.

Female

Male

Work: ( ___ ___ ___ ) ___ ___ ___

___ ___ ___ ___ Home: ( ___ ___ ___ ) ___ ___ ___

___ ___ ___ ___

(Area Code)

___ ___ / ___ ___ / ___ ___ ___ ___

IL486-2363 12/23 (APRN-FPA)

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

Non-examination

Month

Fax: ( ___ ___ ___ ) ___ ___ ___

___ ___ ___ ___ E-MAIL ADDRESS (REQUIRED)

(Area Code)

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

YES

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.

Application for Advanced Practice Registered Nurse License - Page 2 of 2IL486-2363 (APRN-FPA)

PART IV: Child Support and Tax Information (Every applicant is required by law to respond to the following

questions)

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.

Signature of Applicant Date

I UNDERSTAND THAT FEES ARE NOT REFUNDABLE. My signature above authorizes the Department of Financial and

Professional Regulation to reduce the amount of this check if the amount submitted is not correct. I understand this will be done only

if the amount submitted is greater than the required fee hereunder, but in no event shall such reduction be made in an amount greater

than $50.

PART V: Certifying Statement

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.")

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.

NOYES

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

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

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

I hereby certify to the following:

* I have completed at least 250 hours of continuing education or training in compliance with Section 1300.465.

* The CE or training in question is the area of certiﬁ cation used to obtain my APRN license.

* I will provide proof of completion to the Department upon request.

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.

Complete the applicant section of this form.

APPLICANT:

IL486-2366 12/23

AFFIDAVIT

CE / TRAINING

AF-

APRN-FPA

6. MAIDEN OR GIVEN SURNAME

4. ADDRESS STREET, CITY, STATE, ZIP CODE

3. SSN / ITIN

2. DATE OF BIRTH

1. NAME LAST FIRST MIDDLE

SUPPORTING DOCUMENT

Month Day Year

__ __ / __ __ / __ __ __ __

DateSignature of Applicant

DateSignature of Notary

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.

Complete the applicant section of this form.

APPLICANT:

IL486-2367 12/23

VERIFICATION OF EXPERIENCE

VE-

APRN-FPA

6. MAIDEN OR GIVEN SURNAME

4. ADDRESS STREET, CITY, STATE, ZIP CODE

3. SSN / ITIN

2. DATE OF BIRTH

1. NAME LAST FIRST MIDDLE

SUPPORTING DOCUMENT

Month Day Year

__ __ / __ __ / __ __ __ __

DateSignature of Physician or Hospital

Medical Staﬀ Committee/Designee

DateSignature of Applicant

DateSignature of Notary

INSTRUCTIONS: Multiple copies of this form may be submitted to document completion of the required 4000 hours of

clinical experience. The top portion must be completed by the collaborating physician(s) or hospital designee. The bottom

portion must be completed by the Applicant and must be notarized.

I ___________________________________________ hereby certify that the applicant has completed _________ hours

of clinical experience after ﬁ rst attaining national certiﬁ cation in accordance with Section 1300.465 of the Illinois Rules for

the Administration of the Nurse Practice Act.

Name of Physician or Hospital Medical Staﬀ Committee/Designee

NOTE: Only the signature of the applicant must be notarized.

I____________________________________________ hereby certify that I have completed _______ hours of clinical

experience with the above physician or hospital. I agree to provide proof of completion of the hours to the Department

upon request.

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 sub-

mitted 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 dis-

charge, 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? *

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

Marriage and Family Therapist Assoc.

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

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.

Advanced Practice Registered

Nurse - Full Practice Authority

Behavior Analyst

Behavior Analyst Assistant

Music Therapist

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

IL486-2034

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 attempt-

ing 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 de-

fendant 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 sub-

stantially 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

Page 3 of 3

aa) Aggravated Robbery (Section 18-5);

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 #:______________