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INSTRUCTIONS

SOCIAL WORKER (SW) AND CLINICAL SOCIAL WORKER (CSW)

Examination--SW and CSW

Acceptance of Examination--SW and CSW

Endorsement of License--SW and CSW

Restoration - SW and CSW

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, 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 accurately completing your

application and eliminate any delay in processing. THE APPLICATION WHICH YOU SUBMIT IS VALID FOR

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

expire on November 30 of each odd-numbered year.

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

Profession 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) by completing all applicable information requested on all 4 pages

of the Application for Licensure and/or Examination.

NOTE: a) If you have ever held a Certified Social Worker license or Registered Social Worker

license in Illinois, you MUST record this information in PART IV (page three) of the

Application for Licensure and/or Examination.

b) Do not complete PART VII of the Application for Licensure and/or Examination.

Step 3. The remainder of this form contains specific instructions for each Licensure Method. Locate the

instructions 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

fluent 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, a telephone number for assistance in completing the Application Package is provided on the

REFERENCE SHEET.

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

DPR-SW 4/14

PACKET UPDATED 7/11/14

EXAMINATION--CLINICAL SOCIAL WORKER

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.

1. Supporting Document CCA 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 appropriate official of the college or university from which

your graduate degree was obtained. This form must be signed by the school's official and must bear the school

seal.

NOTE: The Supporting Document ED must reflect information regarding the degree upon which you are

basing your application. The degree must be either a M.S.W. or a Ph.D. in social work from an

approved school of social work.

3. Supporting Document VE-SW must verify your supervised clinical professional experience. For persons with

a M.S.W.; 3,000 hours of satisfactory supervised clinical professional experience must be verified. All hours

must have been obtained subsequent to securing the M.S.W. For persons with a Ph.D. in Social Work; 2,000

hours of satisfactory supervised clinical professional experience subsequent to the degree must be verified.

Supporting Document VE-SW must be completed by the person who supervised the applicant.

One Supporting Document VE-SW is enclosed. You are authorized to photocopy the form if necessary.

NOTE: If you hold the Diplomate designation, submit a photocopy of the certificate.

4. If you have ever held a license as a social worker or clinical social worker in a state other than Illinois,

Supporting Document CT must be completed by the state of original licensure and the state of current licensure

where you have most recently been practicing. You are authorized to photocopy the form if necessary. You

must direct the licensing agency/board to return the completed CT form directly to you.

5. 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 the Illinois Department of Financial and Professional Regulation.

6. Forward four-page application, all supporting documentation, and fee payment to the Illinois Department of

Financial and Professional Regulation, Attn: Division of Professional Regulation, P.O. Box 7007, Springfield,

Illinois 62791.

SOCIAL WORKER - PAGE 3

LICENSURE METHODS AND DEFINITIONS

Following are definitions 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 specific licensure methods/requirements for your

profession.

Licensure Methods Definition

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

qualification and practices (for a specified time only).

Non-examination Applicant is licensed by meeting qualifications 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, 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

REFERENCE SHEET

ALL FEES ARE NONREFUNDABLE

Department reserves the right to change examination dates, filing deadlines and fees

if prevailing circumstances necessitate such action.

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

PROFESSION LICENSURE APPLICATION

PROFESSION NAME CODE METHOD FEE

Licensed Clinical Social Worker 149 Examination $ 50.00

Acceptance of Examination $ 50.00

Endorsement of License $200.00

Licensed Social Worker 150 Examination $ 50.00

Acceptance of Examination $ 50.00

Endorsement of License $200.00

Restoration See Supporting Document RS

CHART II - EXAMINATION CODES AND FEES

NOTE:

Since the application for examination is a dual process, you must first complete the Department’s licensure/

examination application. This application is available at

www.idfpr.com

. Select the agency link

Professional

Regulation

; select your profession, scroll to

Social Worker

; select the

written examination

and download the

application. Submit the completed application to IDFPR with the required documentation for approval.

After you have been approved by the Department, you will receive an examination approval letter with the instructions

on how to register to sit for the examination with the Association of Social Work Boards (ASWB), and a Candidate

Handbook.

CHART III - EXAMINATION DATES

INFORMATION WILL BE AVAILABLE ONCE YOU ARE APPROVED FOR THE EXAMINATION

CHART IV - SCHOOL CODES

NOT APPLICABLE FOR LICENSED CLINICAL SOCIAL WORKER or LICENSED SOCIAL WORKER

ENTER N/A IN PART VII c) OF APPLICATION

FOR LICENSURE AND/OR EXAMINATION

REQUEST FOR ASSISTANCE

If assistance is needed, you may call 1-800-560-6420, TTY 1-866-325-4949

DPR-SW-A 7/14

ILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION

SOCIAL WORK EXAMINING AND DISCIPLINARY BOARD

After January 1, 1995, only experience supervised by a licensed clinical social worker will be

acceptable to meet the professional experience requirement. If supervision was in another

jurisdiction in which clinical social workers are not licensed, the supervisor shall be engaged in

clinical social work and be credentialed at the highest level required by that state.

The guidelines used prior to January 1, 1995, for acceptable supervisor/supervision for licensure

as a clinical social worker were as follows:

Supervisors:

1. Supervisor was a certified social worker registered under the Social Workers

Registration Act with clinical experience.

2. Supervisor is a licensed clinical social worker.

3. Supervisor is a diplomate in clinical social work.

4. Supervisor is a member of the Academy of Certified Social Workers.

5. Other clinical supervisor such as:

A. A psychiatrist certified by the American Board of Psychiatry.

B. A licensed clinical psychologist.

C. A person who is licensed in another jurisdiction as a social worker or

psychologist who is engaged in clinical practice. (This applies to jurisdic-

tions where clinical social workers or clinical psychologists are not licensed

by those titles.)

Supervision may be:

1. paid for by an individual.

2. paid for by an individual's employer.

3. provided during employment.

4. provided outside of employment.

5. provided to more than one person at a time as long as each individual receives

one hour of supervision per week.

SW-BD 9/95

APPLICATION FOR

LICENSUREAND/OR EXAMINATION

FOR OFFICIAL USE ONLY

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.

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

different from that shown on your application, you must

submit PROOF OF LEGAL NAME change - copy of mar-

riage license, divorce decree, affidavit or court order.

Carefully follow all steps outlined on the INSTRUCTION SHEET. In

addition, note the following:

A. Type or print legibly with black ink only.

B. FEESARENOTREFUNDABLE.

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 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

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

1. PROFESSION NAME 2. PROFESSIONCODE

3. LICENSURE METHOD

4. FEE

Licensed Clinical Social Worker

1 4 9 Examination

B. CHECKBOXINDICATINGTHEAPPROPRIATEINFORMATIONREGARDINGYOURAPPLICATION

50.00

This is the first 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:

My application for this profession had previously been

denied in Illinois. I am reapplying since I have fulfilled

additional requirements.

I have previously made application for this profession in

Illinois. However, I am now applying under new statutory

language.

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 file this

application in order to receive any further information.

1. NAME

LAST

FIRST

MIDDLE

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

UNITED STATES SOCIAL SECURITY NO.

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

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

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

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

7. M

OTHER'SMAIDENNAME

8. PLACE OF BIRTH CITY STATE/COUNTRY

9. DATE OF BIRTH

Month

Day Year

10. AGE

Female

Male

11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED

Work: ( ) Home: ( )

(Area Code)

Fax: ( ) Fax: ( )

(Area Code)

12. PREFERREDe-MAIL

ADDRESS(ES) [If available]

IL486-1019 01/14 (LT) APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4

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

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

PART III: Education Information

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

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

Graduated Received

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

2. NAME OF LAST PRELIMINARY SCHOOL

ATTENDED

3. LAST PRELIMINARY SCHOOL LOCATION

(City and State)

4. DATE OF GRADUATION

Month Year

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

1 2 3 4 5 6 7 8 Graduated? Yes No

6. COLLEGE OR UNIVERSITY NAME

(Undergraduate and Graduate)

LOCATION

(

City and State or Country)

DATES OF ATTENDANCE

TYPE OF

DEGREE EARNED

FROM

Month/Year

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

INSTITUTION NAME

LOCATION

(

City and State or Country)

DATES OF ATTENDANCE

Did You Complete

Training?

FROM

Month/Year

Yes No

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

IL486-1019

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

PART IV: Record of Licensure Information

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 Certification(s) of Licensure 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, certification 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 PROFESSION NAME LICENSE NUMBER

DATE OF

ISSUANCE

LICENSESTATUS

(Active, Lapsed, etc.)

State of Original Licensure

State of Current Licensure where you

most recently have been practicing.

Other States of Licensure

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

PART V: Record of Examination

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.

NAME OF EXAMINATION

STATE

MONTH/YEAR EXAM RESULTS

(Passed, Failed, Absent)

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

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

IL486-1019

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

PART VI: 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 offense in any state or in federal court? Please do not give

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

opy of the court records regarding your conviction, the nature of the offense and date of discharge, if applicable, as well as a statemen

rom the probation or parole office.

2. Have you been convicted of a felony?

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. Have you had or do you now 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, i.e., (1) mental or emotional diseas

or c

ondition; (2) alcohol or other substance abuse; (3) physical disease or condition, that presently interferes with your ability to practic

our profession? 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.

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:

N/A

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:

PART VIII: Child Support and/or Student Loan 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 complyin

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

icensee 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 Illinois Compiled Statutes 2105/2105-(5), "The Department shall deny any license or renewal authorized by the Civil

Administrative Code of Illinois to any person who has defaulted on an educational loan or scholarship provided by or guaranteed by the Illinois

Student Assistance Commission or any governmental agency of this State; however, the Department may issue a license or renewal if the

aforementioned persons have established a satisfactory repayment record as determined by the Illinois Student Assistance Commission o

her appropriate governmental agency of this State." (Proof of a satisfactory repayment record must be submitted.)

Are you in default on an educational loan or scholarship provided/guaranteed by the Illinois

Student Assistance Commission or other governmental agency of this State? Yes No

PART IX: 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.

IL486-1019

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

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.

HEALTH CARE WORKERS

CHARGED WITH OR CONVICTED

OF CRIMINAL ACTS

SUPPORTING DOCUMENT

CCA

1. NAME LAST FIRST MIDDLE

3. PROFESSIONAL LICENSE NUMBER (if any)

2. ADDRESS STREET,

CITY,

STATE,

ZIP CODE

4. SOCIAL SECURITY NUMBER

- -

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

tions pertaining to certain offenses. Please check applicable profession.

Acupuncturists Naprapaths

Physician Assistants

Advanced Practice Nurses

Nursing Home Administrators

Podiatrists

Athletic Trainers

Occupational Therapists

Professional Counselors

Audiologists

Occupational Therapy Assistants

Prosthetists

Clinical Psychologists

Optometrists

Registered Nurses

Clinical Social Workers

Orthotists

Registered Surgical Assistants

Dental Hygienists

Pedorthists

Registered Surgical Technologists

Dentists

Perfusionists

Respiratory Care Practitioners

Genetic Counselors

Pharmacists

Speech Pathologists

Licensed Clinical Professional

Physical Therapists

Counselors

Physical Therapy Assistants

Licensed Practical Nurses Physicians, including Medical Doctors

Licensed Social Workers (M.D.), Doctors of Osteopathic Medicine

Marriage and Family Therapists

(D.O.), and Chiropractic Physicians (D.C.)

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.

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

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

Yes

the S

ex Offender Registration Act? *

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

ourse of patient care or treatment, including any offense based on sexual conduct or sexual penetration?

Are you r

equired, as part of a criminal sentence, to register under the Sex Offender Registration Act? *

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

If YES to any of the above, attach a certified copy of the court records regarding your conviction, the nature of the offense

and date of discharge, if applicable, as well as a statement from the probation or parole office.

Certification 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.

Signature of Applicant Date

IL486-2034 02/13 (crimacts) Page 1of 3

* DEFINITIONS

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

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

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

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).

An attempt to commit any of these offenses.

(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 def

endant is not a parent of the victim, the offense was sexually motivated as defined in Section 10 of the Sex Offender

Management Board Act, and the offense was committed on or after January 1, 1996:

10-1 (kidnapping),

10-2 (aggravated kidnapping),

10-3 (unlawful restraint),

10-3.1 (aggravated unlawful restraint).

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 offense, provided the offense was sexually

motivated as defined in Section 10 of the Sex Offender Management Board Act.

(Blank).

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

offense was committed on or after June 1, 1997.

ild 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 offense was committed on or after January 1,

1998, provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.

A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was

committed on or after July 1, 1999:

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

defined in S

ection 10 of the Sex Offender 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 offense 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 offense

was c

ommitted on or after August 22, 2002.

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

(C) A conviction for an offense of federal law, Uniform Code of Military Justice, or the law of another state or a foreign country tha

is s

ubstantially equivalent to any offense listed in subsections (B), (C), (E), and (E5) of this Section shall constitute a conviction fo

the purpose of this Article.

IL486-2034 02/13 (crimacts) Page 2of 3

* 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 offenses:

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) Trafficking 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) Vehi

cular Hijacking (Section 18-3);

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

aa) Aggravated Robbery (Section 18-5);

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 specified offenses.

IL486-2034 02/13 (crimacts) Page 3of 3

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.

CERTIFICATION BY LICENSING

AGENCY / BOARD

SUPPORTING DOCUMENT

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

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

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

1. NAME LAST FIRST MIDDLE

2. DATE OF BIRTH

/ /

Month Day Year

3. SOCIAL SECURITY NUMBER

- -

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.

Profession Name Profession Code

6. MAIDEN OR GIVEN SURNAME

7. APPLICANT TELEPHONE NUMBER (Daytime)

Area Code ( )

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

FROM THE JURISDICTION TO WHICH THIS FORM IS BEING

FORWARDED. (If applicable)

8b. LICENSE NUMBER (If

applicable)

8c. ISSUANCE DATE OF LICENSE

(If applicable)

I hereby authorize to furnish to the Illinois Department of

Name of Licensing Agency or Board

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

Signature Date

RETURN COMPLETED FORM TO APPLICANT

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

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

the certification. 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:

Name of Examination Date of Examination

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

PART II - CERTIFICATION OF LICENSURE

A. NAME OF PROFESSION AS IT APPEARS ON LICENSE B. LICENSE NUMBER

C. ISSUANCE DATE OF LICENSE D. EXPIRATION DATE OF LICENSE

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)

Reciprocity with (State)

Waiver/Grandfather

Credentials

Other (Describe)

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

IL486-0850 04/06 (LT)

CT - Certification by Licensing Agency/Board - Page 1 of 2

SUBJECT

DATE

SCORE

SUBJECT

DATE

SCORE

SUBJECT

DATE

SCORE

SUBJECT

DATE

SCORE

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

PART III - CERTIFICATION OF EXAMINATION SCORES

A1. National or other Profession Specific Examination Date of Examination

(Record all available information)

Scaled Score Raw Score

Standard Deviation

Corrected

Score National Mean

Percent Score

A 2.

B. State Constructed Examination

PART IV - FORMAL ACTIONS

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 fine, reprimand, probation, censure, revocation, suspension,

surrender, restriction or limitation? (If yes, attach a certified 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.

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

Print Name

S E A L

Title Signature

Agency/Board Street Address

Date

Area Code ( )

City, State, ZIP Code Telephone Number

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

Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET.

IL486-0850 04/06 (LT)

CT - Certification by Licensing Agency/Board - Page 2 of 2

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.

CERTIFICATION OF EDUCATION

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

2. DATE OF BIRTH

/ /

Month Day Year

3. SOCIAL SECURITY NUMBER

- -

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.

Licensed Clinical Social Worker 1 4 9

Profession Name Profession Code

6. MAIDEN OR GIVEN SURNAME

7. NAME OF INSTITUTION ATTENDED

Loyola University Chicago

8. DATE OF GRADUATION / COMPLETION

/ /

Month Day Year

I hereby authorize a school official of the institution named above to furnish to the Illinois Department of Financial and

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

Date Signature of Applicant

SCHOOL OFFICIAL: Complete the bottom portion of this page and the reverse side. RETURN THE COMPLETED

FORM TO THE APPLICANT.

A. NAME OF INSTITUTION

Loyola University Chicago

B. ADDRESS OF INSTITUTION STREET, CITY, STATE, ZIP CODE

820 N. Michigan Ave. Chicago, IL 60611

C. DEPARTMENT OF INSTITUTION

School of Social Work

D. SPECIFIC PROGRAM OR CURRICULUM CONCENTRATION OF

APPLICANT

Clinical Social Work

E. MAJOR AREA OF STUDY OF THE APPLICANT

Social Work

F. APPLICANT WAS (CHECK ONE):

Full-time Part-time Co-op

G. CREDIT HOURS EARNED

(CHECK ONE AND

Semester Hours

COMPLETE)

Quarter Hours

Course Hours

H. DATES OF ATTENDANCE

From / / To / /

Month Day Year Month Day Year

Total academic years attended

Years Months Days

Total calendar years attended

Years Months Days

J. TYPE OF DEGREE OR CERTIFICATE AWARDED

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

MSW

K. DATE THAT DEGREE OR CERTIFICATE REQUIREMENTS WERE MET

/ /

Month Day Year

L. DATE THAT DEGREE OR CERTIFICATE WAS CONFERRED

/ /

Month Day Year

M. CHECK THE APPROPRIATE STATEMENT(S) AND COMPLETE

Applicant has graduated on / /

Month Day Year

Applicant will graduate on / /

Month Day Year

Applicant has completed program on / /

Month Day Year

Applicant will complete program on / /

Month Day Year

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

IL486-1306 03/06 (LT)

ED - Certification of Education - Page 1 of 2

NAME (Last, First, MI): ______________________________________________ SS#: _____________________ Profession: _____

____________

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

HE APPLICANT'S EDUCATIONAL EXPERIENCES.

I c

ertify that the information recorded herein is true and correct according to the official records of this institution.

Amy Greenberg, LCSW, MA.Ed., PEL

Signature of School Official Print Name of School Official

Assistant Dean for Student Affairs

Title Date

CHOOL SEAL OR NOTARY SEAL

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

CHOOL OFFICIAL: RETURN THIS FORM TO APPLICANT

ATTENTION APPLICANT: FOR INCLUSION WITH THE APPLICATION PACKET.

IL486-1306 03/06 (LT)

ED - Certification of Education - Page 2 of 2

IMPORTANT NOTICE: Completion of this form

is necessary for consideration for licensure

under 225 ILCS 20/1 et. seq. (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

VE-SW

APPLICANT: Complete the applicant section of this form, then forward it to your employer. You are authorized

to photocopy this form as necessary.

1. NAME LAST FIRST MIDDLE

2. DATE OF BIRTH

/ /

Month Day Year

3. SOCIAL SECURITY NUMBER

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 applica-

tion.

Profession Name Profession Code

6. MAIDEN OR GIVEN SURNAME

COMPLETE BOXES 7, 8, 9 AND 10 TO REFLECT INFORMATION AT TIME OF EMPLOYMENT/EXPERIENCE

7. SUPERVISOR NAME

8. BUSINESS/INSTITUTION NAME

9. SUPERVISOR TITLE

10. ADDRESS STREET, CITY, STATE, ZIP CODE

SUPERVISOR: Complete the remainder of this form. RETURN THE COMPLETED FORM DIRECTLY TO THE

APPLICANT IN A SEALED ENVELOPE. If the supervisor was other than a Certified Social Worker,

A.C.S.W., a Licensed Clinical Social Worker, or a Diplomate in Clinical Social Work, it is requested

the supervisor provide a copy of his curriculum vitae or professional/educational credentials.

PART I. - SOCIAL WORK SUPERVISION INFORMATION

A. IMMEDIATE/DIRECT SUPERVISOR'S NAME

B. BUSINESS/INSTITUTION NAME

C. REGISTRATION NUMBER

D. REGISTRATION STATE

E. BUSINESS ADDRESS STREET, CITY, STATE, ZIP CODE

F. PROFESSIONAL DESIGNATION (Date Awarded)

Illinois L.C.S.W. Diplomate

Illinois L.S.W. Clinical S.W.

A.C.S.W. Other:

L.C.S.W.

G. BUSINESS TELEPHONE NUMBER

Area Code ( )

PART II. - APPLICANT EMPLOYMENT INFORMATION

A. APPLICANT'S JOB TITLE AT TIME OF EMPLOYMENT/ EXPERI-

ENCE

B. DATES OF APPLICANT'S EMPLOYMENT/EXPERIENCE

From / / To / /

Month Day Year Month Day Year

C. NUMBER OF HOURS APPLICANT WORKED PER WEEK

D. NUMBER OF HOURS YOU MET WITH THE APPLICANT PER

WEEK

IL486-0369 05/06 (SW)

VE-SW - Verification of Employment/Experience - Page 1 of 2

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

PART II. - APPLICANT EMPLOYMENT INFORMATION (Continued)

E. INDICATE YOUR OVERALL EVALUATION OF THE APPLICANT'S PERFORMANCE UNDER YOUR DIRECT SUPERVISION

Circle One Excellent Satisfactory Poor

5 4 3 2 1

F. COMMENTS ABOUT APPLICANT'S JOB PERFORMANCE:

G. INDICATE PERCENTAGE OF APPLICANT'S TIME SPENT IN THE FOLLOWING AREAS:

PERCENT OF TIME WORKED

SERVICE AREA

1. Psychosocial assessments

2. Therapeutic interventions

3. Casework services

4. Community organization

5. Management/supervision

6. Educational experiences

7. Research

8. Teaching

The above indicated experience has been documented by myself and has been performed by the applicant pursu-

ant to my order, control, and full professional and legal responsibility as a supervisor. I do hereby declare that the

information contained herein is true and correct.

Signature

Date Title

IL486-0369 05/06 (SW)

VE-SW - Verification of Employment/Experience - Page 2 of 2