IL486-2396 11/20
Illinois Department of Financial and Professional Regulation
Division of Professional Regulation
PLEASE TYPE AND SUBMIT ELECTRONICALLY
License No: _____________________ SSN (Last four only): ______________ Date of Birth: ____________________
First Name: ________________________________ Last Name: ___________________________________________
Address: _______________________________________________________________________________________
City: ________________________________________ State: ____________________ Zip: ____________________
Phone Number: __________________________ Email Address: ___________________________________________
CHECK HERE IF NAME OR ADDRESS CHANGE. A name change must be accompanied by documentary proof.
Proof must be one of the following: Marriage Certifi cate, Divorce Decree, Court Order, or an Offi cially Issued State ID
(Driver's License, Passport).
CHECK THE APPROPRIATE ANSWER BELOW:
Are you more than 30 days delinquent in complying with a child support order? NOTE: If you are not subject to a child
support order, answer “No”.
NO YES
FITNESS TO PRACTICE: Do you have any disease or condition that interferes with your ability to perform the
essential functions of your profession, including any disease or condition generally regarded as chronic by the
medical community? If yes,attach a detailed statement, including an explanation whether or not you are currently
under treatment. NO YES
PURSUANT TO 20ILCS 2105-165(a), the Department requires the disclosure of information regarding convictions
pertaining to certain off enses for this profession. You must respond to each of the following questions:
1) Are you currently charged with or have you been convicted of a criminal act that requires registration under the Sex
Off ender Registration Act? NO YES
2) 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? NO YES
3) Are you required, as part of a criminal sentence, to register under the Sex Off ender Registration Act
NO YES
4) Are you currently charged with or have you been convicted of a forcible felony? NO YES
Under penalty of perjury, I declare that I have examined this form and, to the best of my knowledge, all statements are
true, correct and complete.
Signature: ______________________________________________________ Date: ___________________________
FOR EXPEDITED REVIEW AND SERVICE, EMAIL COMPLETED FORM TO: fpr.covidtemporaryapplication@illinois.gov.
Reinstatement of Illinois Health Care License - COVID-19
This application is specifi c to the COVID-19 Pandemic and limited to prior State of Illinois licensees
who were in good standing and in the following professions only: Licensed Practical Nurse, Advanced
Practice Registered Nurse, Registered Nurse, Physician Assistant and Respiratory Care Practitioner.
Your license must have been active and in good standing as of January 1, 2016. License will have an
expiration date of 5/31/2021 and a $0.00 fee.
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