Affidavit re: Waiver of SSN Requirement

I, the undersigned affiant whose name and birthdate appears below, hereby do declare:

1. I am an adult of sound mind and body and have the capacity to make this declaration.
2. I am currently not physically present in the United States of America.
3. I do not currently have a U.S. Social Security number.
4. As an applicant for licensure as a Registered Nurse in the state of Illinois, I understand that the
lack of a U.S. Social Security number at the time of initial application may be waived and
therefore request such a waiver.
5. I also acknowledge that I am required to obtain a U.S. Social Security number and report such
number to the state of Illinois, Board of Nursing within 2 years of my being granted a license as a
Registered Nurse, and that failure to do so can result in cancellation of my license.

I hereby declare that the forgoing is true and correct, and hereby affix my signature in the presence of a
Notary.

Name of Affiant:

Date of Birth of Affiant:

_________________________________
Signature of Affiant

Notarization [Jurat or stamp]