Applicant Scheduling – Evansville | Public Safety Medical

Name of Department *

Name of Person Making Request *

Title of Person Making Request *

Email of Person Making Request *

Direct Phone Number of Person Making Request *

Please Provide your Department's Mailing Address *

Name of Chief of Department *

Direct Phone Number of Chief of Department *

Email of Chief of Department *

Do You Want the Applicant(s) to Pay for Any Portion of the Evaluation? *

Yes

No

Please Indicate Your Preference on What the Applicant(s) Should Pay. *

50% of Medical and Psychological Evaluation

50% of Medical Evaluation Only

50% of Psychological Evaluation Only

Your applicant's results will be sent to you via secure e-mail. Please contact Chad with questions at 317.964.2364.

Who Should Receive the Results? (check all that apply) *

"Person Making Request" above

The Chief Named Above

Someone Else other than the applicant

Name to Whom Results should be Sent *

Title of Results Contact *

Email of Results Contact *

Direct Phone Number of Results Contact *

All Invoices Will Be Sent By Email To:

Name to Send Invoice To: *

Title

Clerk / Treasurer

Accounts Payable

Email *

Phone *

Do You Require a Purchase Order? *

Yes

No

Please attached PO if Possible

Maximum file size: 2MB

Mailing Address *

Number of Applicants to be Scheduled (up to 5) Please Note: PSM will not contact applicants directly.

Please provide several dates that each applicant will be available. If more than 5 applicants, please call Alexis in Special Services at 317.964.2339.

Enter Number of Applicants You are Scheduling *

Choose from drop-down list

Position that Applicant(s) are Applying For *

Choose from drop down list

Please List "Other" Position

Results are estimated to be prepared within 12 business days of the appointment.

If applicable, has a Conditional Offer of Employment Been Made to the Applicant(s)? *

Yes

No

Not applicable

Please Provide Date that a Conditional Offer will be Made. *

Please Indicate Type of Evaluation.

What Type of Applicant Evaluation Do You Need? *

Indiana PERF (1977 Police Officers’ and Firefighters’ Pension Fund)

Ohio Police & Fire Pension Fund

Another Pension Fund

Non-Pension Fund

Please provide the name of the Pension Fund

All services are performed in one location in one day.

Which of the Following Do You Want Performed? *

Medical and Psychological Evaluation

Psychological Evaluation Only

Medical Evaluation Only

Please Select (or type in) Any Additional Testing that You Would Like Performed. (All Applicant Testing for Departments not on a Pension will be Based Upon Indiana's 1977 Fund Testing Requirements.)

Treadmill Stress Test

Hepatitis B Titer

Muscular Fitness Evaluation

OtherOther

What is your anticipated hire date? *

Applicant(s) can only pay by credit or debit card (if applicable).

Please Provide the Following Information on Each Applicant.

Applicant #1 Full Legal Name *

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #1 Date of Birth *

Enter as MM/DD/YYYY

Applicant #1 Gender *

Male

Female

Is Applicant #1 Is this person currently enrolled in the 1977 Police and Firefighter pension fund?

Yes

No

Applicant #1 Please Type in any Dates the Applicant WILL be Available for Scheduling *

Applicant #2 Full Legal Name

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #2 Date of Birth *

Enter as MM/DD/YYYY

Applicant #2 Gender

Male

Female

Is Applicant #2 Is this person currently enrolled in the 1977 Police and Firefighter pension fund?

Yes

No

Applicant #2 Please Type in any Dates the Applicant WILL be Available for Scheduling

Applicant #3 Full Legal Name

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #3 Date of Birth *

Enter as MM/DD/YYYY

Applicant #3 Gender

Male

Female

Is Applicant #3 Is this person currently enrolled in the 1977 Police and Firefighter pension fund?

Yes

No

Applicant #3 Please Type in any Dates the Applicant WILL be Available for Scheduling

Applicant #4 Full Legal Name

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #4 Date of Birth *

Enter as MM/DD/YYYY

Applicant #4 Gender

Male

Female

Is Applicant #4 Is this person currently enrolled in the 1977 Police and Firefighter pension fund?

Yes

No

Applicant #4 Please Type in any Dates the Applicant WILL be Available for Scheduling

Applicant #5 Full Legal Name

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #5 Date of Birth *

Enter MM/DD/YYYY

Applicant #5 Gender

Male

Female

Is Applicant #5 Is this person currently enrolled in the 1977 Police and Firefighter pension fund?

Yes

No

Applicant #5 Please Type in any Dates the Applicant WILL be Available for Scheduling

PLEASE CLICK "SUBMIT" AT BOTTOM OF SCREEN

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