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Get IL IL486-1314 2014

/1et. seq. Disclosure of this information is REQUIRED. However, failure to comply may result in this form not being processed. Agency / Licensee Number - This box to be completed by the Division of Professional Regulation: THIS SECTION TO BE COMPLETED BY APPLICANT/LICENSEE 1. NAME OF EMPLOYEE/LICENSEE TO WHICH CARD WILL BE ISSUE (Last, First, Middle Initial) 4. INDIVIDUAL LICENSE NUMBER, IF APPLICABLE (115-, 119-, or 124 Only use one prefix.) 3. PERMANENT EMPLOYEE REGISTRATION NUMBER 129- .

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