Get Il452na01

The Il452na01 is a crucial form for applicants seeking to establish a nurse agency in Illinois. This guide will provide you with clear, step-by-step instructions on how to successfully complete this form online, ensuring a seamless application process.

Follow the steps to fill out the Il452na01 accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the digital editor.
2. Select the type of application you are submitting by checking either 'New' or 'Renewal' in the type of application section.
3. Indicate the legal structure of your business by selecting one of the options: Corporation, Sole Proprietor, Partners, LLC, LLP.
4. Fill in the business name and address where your agency will operate. Include city, county, telephone number, state, and zip code.
5. Provide your Federal Employer Identification Number (FEIN) or Social Security Number (SS#) as applicable.
6. Indicate whether your agency has ever been licensed under another name by selecting 'Yes' or 'No,' and provide that name if applicable.
7. Complete the section for the principal officer, including their name, residence address, and any contact information required.
8. Confirm whether the principal officer has ever been convicted of a felony by checking 'Yes' or 'No.'
9. List the number of employees you reported on your last quarterly UI3-40 form for CNAs, LPNs, and RNs.
10. Detail the responsibilities and personnel by listing their names and roles according to the specified categories in the form.
11. Attach a current copy of the RN's license and verification from the Illinois Department of Professional Regulations.
12. Fill out the sections for corporate officers, directors, and shareholders, ensuring all required names and addresses are accurately recorded.
13. Complete the statement of financial solvency, confirming your agency’s financial stability by addressing each item listed.
14. Sign and date the application, ensuring that the individual is authorized to complete the form on behalf of the agency.
15. Review your completed application for accuracy, then save changes, download or print the form, and share it as needed.

Ensure your agency's license application is filled out correctly online and submit it promptly!