Out Of State Nurse Application - Illinois Department of Public Health - idph state il 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your full name, address, and telephone number. Ensure that all details are typed clearly for easy readability.
3. Provide your Social Security Number as it is a required field. Next, list the states where you have been certified as a CNA and include any previous names if applicable.
4. Fill in the demographic information such as sex, race, height, eye color, and date of birth. This data is solely for identification purposes.
5. Indicate whether you have had any administrative findings of abuse or criminal convictions. If applicable, provide detailed explanations in the space provided.
6. Review your entries for accuracy before signing and dating the application at the bottom. If you are a guardian completing this form for someone under 17, ensure to sign accordingly.
7. Once completed, save your document and follow the instructions to mail it to the Illinois Department of Public Health.

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