INSTRUCTION / INFORMATION SHEET

INSTRUCTION / INFORMATION SHEET

ADVANCED PRACTICE REGISTERED NURSE -

FULL PRACTICE AUTHORITY (Profession Code - 277)

Certified Nurse Midwife Certified Nurse Practitioner

Certified Clinical Nurse Specialist

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.

Note:

A CURRENT ILLINOIS REGISTERED NURSE LICENSE AND A CURRENT ILLINOIS ADVANCED PRACTICE REGISTERED NURSE LICENSE ARE REQUIRED FOR FULL PRACTICE AUTHORITY.

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

following pages. Locate the instructions for specific 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 assistance 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 Professional 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 Springfield, 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.

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.

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: idfpr.

DPR APRN-FPA Instructions Revised 3/22

Packet Revised on 4/15/22

CERTIFIED NURSE MIDWIFE

Submit the following documents and/or forms with the two-page application and fee: 1. Supporting Document CCA 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 certification (certification or pocket card accepted) from one of the following:

The American College of Nurse Midwives (ACNM); OR The American College of Nurse Midwives Certification Council (ACC) 3. Affidavit 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

Submit the following documents and/or forms with the two-page application and fee: 1. Supporting Document CCA 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 certification (certification or pocket card accepted) from one of the following:

American Academy of Nurse Practitioners Certification Program as a Nurse Practitioner American Nurses Credentialing Center as a Nurse Practitioner The Pediatric Nurse Certification Board as a Nurse Practitioner The National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties as a

Nurse Practitioner The Certification Board for Urologic Nurses and Associates as a Urologic Nurse Practitioner. 3. Affidavit 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 2

CERTIFIED CLINICAL NURSE SPECIALIST

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

1. Supporting Document CCA 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 certification (certification 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 Certification Board as a Certified Rehabilitation Registered Nurse--Advanced Oncology Nursing Certification Corporation as an Advanced Oncology Certified Nurse (AOCN) Certification 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 Certification of Emergency Nurses Certification Board of Perioperative Nurses, Inc. Certification of Pediatric Oncology Nurses Certification Board of Gastroenterology Nurses Dermatology Certification Board International Board of Lactation Consultants International Nurses Society of Addictions IV Nurses Certification Corporation National Association of School Nurses, Inc. National Board of Certification of Hospice and Palliative Nurses National Certification Board for Diabetes Educators National Certification Board of Pediatric Nurse Practitioners/Nurses National Certification Corporation for the Obstetric, Gynecological and Neonatal Nursing Specialties National Certifying Board for Ophthalmic Registered Nurses Nephrology Nursing Certification Board Oncology Nursing Certification Corporation Orthopedic Nurses Certification Board Rehabilitation Nursing Certification Board Vascular Nursing Certification Board Wound, Ostomy, and Continence Society

3. Affidavit 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

SPECIAL INSTRUCTIONS FOR APPLICANTS SEEKING LICENSURE IN MORE THAN ONE ADVANCED PRACTICE NURSING CATEGORY

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 CCA 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 official transcripts with the school seal affixed that he/she possesses an additional graduate

education that results in a certificate for another clinical advanced practice nurse category and that meets the requirements for the national certification from the appropriate nursing specialty; and

3. He/she submits a copy of a current, national certification from the appropriate certifying body for that additional advanced practice nursing category.

Advanced Practice Nurse License - Page 4

IMPORTANT NOTICE Elder and Child Abuse Reporting

"Pursuant to Public Act 91-0244, effective 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 financial 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

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

TWO-PAGE APPLICATION REVIEW Part I. Application Category Information

COMPLETED

Part II. Applicant Identifying Information

Part III. Personal History Information

Part IV. Child Support and/or Taxes

Part V. Certifying Statement--Signed and Dated

SUPPORTING DOCUMENTS 2-page Application for Licensure and/or Examination

Application Fee--$125;

SUBMITTED

Supporting Document CCA must be completed and submitted with each application. Your application will not be processed without completion of this form. 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

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

IL486-1971 (APRN-FPA) 6/19

for your specific method of licensure.

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

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.

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

The following materials are required to make application for an Advanced Practice Nursing license in Illinois:

1. APPLICATION FOR ADVANCED PRACTICE NURSE LICENSURE.

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 different from that shown on your application, you must submit PROOF OF LEGAL NAME change - copy of marriage license, divorce decree, affidavit or court order.

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 file a tax return, pay tax, penalty or interest shown in a filed return, or to pay any final assessment or tax penalty or interest, as required by any tax Act administered by the Illinois Department of Revenue, or to other entities for verification of identification.

PART I: Application Category Information

1. PROFESSION NAME

Advanced Practice Registered Nurse Full Practice Authority

2. PROFESSION CODE

277

3. LICENSURE METHOD

Non-examination

4. FEE

$125

5. CHECK ONE OF THE FOLLOWING BOXES INDICATING THE CATEGORY OF ADVANCED PRACTICE NURSE:

Certified Clinical Nurse Specialist Certified Nurse Practitioner Certified Nurse Midwife

6. INDICATE YOUR CURRENT ILLINOIS REGISTERED NURSE AND APRN LICENSE NUMBERS:

041209 -

PART II: Applicant Identifying Information

1. NAME LAST

FIRST

MIDDLE 2. TITLE (e.g., APN Specialty) 3. UNITED STATES SOCIAL SECURITY NO.

4. PERMANENT MAILING ADDRESS

CITY

STATE/COUNTRY

ZIP CODE

COUNTY

+

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

6. PLACE OF BIRTH (CITY, STATE/COUNTRY)

7. DATE OF BIRTH

8.

___ ___ / ___ ___ / ___ ___ ___ ___

Month Day

Year

Female Male

9. TELEPHONE NUMBER WHERE YOU MAY BE REACHED

Work: ( ___ ___ ___ ) ___ ___ ___ __ ___ ___ ___ ___

(Area Code)

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

(Area Code)

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

(Area Code)

E-MAIL ADDRESS (REQUIRED)

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

1. Have you been convicted of or pled guilty or nolo contendere to any criminal offense in any state or in federal court? Please do not give YES NO

details on minor traffic 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 certified copies of court records of your conviction including the nature of the offense, date of discharge, and a statement from the probation or parole office. 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 Certificate of Relief from Disabilities by the Prisoner Review Board? If yes, attach a copy of the certificate.

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.

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

IL486-2363 3/22 (APRN-FPA)

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

NAME (Last, First, MI): ______________________________________________SS#: _____________________ Profession: ___________________

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

5. Have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license or permit YES NO

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.

PART IV: Child Support and Tax Information (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? (NOTE: If you are not subject to a child support order, answer "no.")

Yes

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 file a return, or to pay the tax, penalty, or interest shown in a filed return, or to pay any final 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 satisfied."

Are you delinquent in the filing of state taxes?

Yes

No

PART V: Certifying Statement

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.

IL486-2363 (APRN-FPA)

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

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