Free 48105.xls - Indiana

ROSTER FOR STUDENTS PARTICIPATING IN COGNITIVE EXAMINATIONS
State form 48105 (R / 8-07) Pursuant to

INDIANA DEPARTMENT OF HOMELAND SECURITY 302 W WASHINGTON ST RM E239 Indianapolis IN 46207 Phone 800-666-7784 Fax 317-233-0497

Reset Form

655 IAC 1-1-12 section (k)(3) and (4). All students names that are taking the written

cognitive examination must appear on this roster. This roster shall be sent to the DHS office not less than 15 days prior to the written examination being conducted.

Test location Name of student

Proctor

Name of test

Date of test IN

Time of examination OUT IN OUT

Driver license number or State ID number