Illinois Department of Financial and Professional Regulation
The Illinois Department of Financial and Professional Regulation, in cooperation with the Illinois Department of Public Health, requires the following information to be completed and returned.  This information is confidential.
Associates
Bachelors
Masters
PhD
Other:
Yes
No
Black / African American
White
American Indian / Alaskan Native
Asian
Native Hawaiian / Pacific Islander
Other
Hispanic
Non-Hispanic
Male
Female

Yes No
General dentistry Periodontics
Pediatric dentistry
Other:
(01) Private Practice / Group Practice (05) VA or General Hospital
(02) Healthcare Business / Corporation (06) Nursing Home / Assisted Living
(03) Academic Setting / Teaching (07) Community Health Center / Not-for-Profit
(04) State / Local Government
(80) Other:
I am not currently practicing.
(Use the 2-digit code from above to complete the following section.)
Practice setting type code (from above)
If clinical, hours per week with patients.
County
ZIP Code
Primary Practice Location
Secondary Practice Location (if applicable)

Yes No

THANK YOU.