Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the facility name and your name in the corresponding fields. Ensure that you have accurate information to avoid any discrepancies.
3. Enter your sex, social security number, and position in the designated areas. Keep in mind that the social security number is used for identity verification.
4. Provide your date of birth, place of birth, and residence address, including city, state, and zip code. Accurate residence information is necessary for your application's processing.
5. Input your telephone number in the specified format. Make sure it is a number where you can be easily reached.
6. Enter your professional registration numbers, including Illinois Professional Medical License Number, Illinois Controlled Substances License Number, Drug Enforcement Administration Registration Number, and Professional Certification Number.
7. Indicate whether your registration is in good standing by selecting 'Yes' or 'No.' This is critical for your licensing review.
8. If you are engaged in other professional practice, mark 'Yes' or 'No' and specify the details of your other practice if applicable.
9. Summarize your previous associations with alcoholism and substance abuse programs, noting the names, locations, and dates of those associations.
10. Respond to questions regarding felony convictions and any governmental license suspensions or revocations by choosing 'Yes' or 'No.'
11. Confirm you have read the Department of Human Services Rule Part 2060 by selecting 'Yes' or 'No.' This acknowledgment is mandatory.
12. Provide your signature and date to complete the form.
13. Once all fields are completed, review your form for accuracy. You can then save your changes, download, print, or share the completed form as necessary.

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