CDL Scheduling

Please use the following form to request a CDL Evaluation.  If you have more than 5 employees needing an appointment, please contact Stacy at 317.964.2355.

For information from the Indiana BMV on obtaining a CDL license, click here.  For information on the national requirements from the Federal Motor Carrier Safety Administration (FMCSA), click here.

We will e-mail you an appointment confirmation within 1 business day or contact you by phone if there are any questions related to your request.  Thank you.

If you are human, leave this field blank.

Company or Department Name *

First and Last Name of Person Making Request *

Title *

Direct Phone Number of Person Making Request *

enter area code and 7-digit phone number

Email of Person Making Request *

Is this your first use of this Form for 2018 appointments? *

Yes

No

Please Provide Your Mailing Address *

Do you want to receive an emailed copy of this submission? *

Yes

No

Results are sent via secure e-mail. Please contact Jane with questions at 317.964.2353.

Who Should Receive Results? *

Same "Person Making Request" Above

Someone Else

Please Provide E-mail Address of Results Contact *

Please Provide the Direct Phone Number of the Results Contact *

Who Should Receive the Invoice? *

Same "Person Receiving Results" above

Someone else

Billing Preference *

E-mail scan

Regular mail (snail mail)

Please Provide Billing Address *

Invoice Should Be Sent To:

Name Invoice Should Be Sent To *

Title *

E-Mail *

Phone *

Billing Preference *

E-mail scan

Regular mail (snail mail)

Billing Address *

Number of Employees to be Scheduled *

Enter as 1, 2, 3, 4 or 5. If more than 5 employees, please call Stacy at 317.964.2355

Are Your Drivers Required to Hold a CDL? *

Yes

No

Would You Like Public Safety Medical to Send the Drivers' CDL Paperwork to the BMV? *

Yes

No

Please provide all information requested below for each appointment needed.

Employee #1 Name *

Employee #1 Date of Birth *

enter month/day/year

By what date do you need to get this individual scheduled? *

Employee #2 Name *

Employee #2 Date of Birth *

enter month/day/year

By what date do you need to get this individual scheduled? *

Employee #3 Name *

Employee #3 Date of Birth *

enter month/day/year

By what date do you need to get this individual scheduled? *

Employee #4 Name *

Employee #4 Date of Birth *

enter month/day/year

By what date do you need to get this individual scheduled? *

Employee #5 Name *

Employee #5 Date of Birth *

enter month/day/year

By what date do you need to get this individual scheduled? *

Please Provide Any Other Notes or Comments:

If this Form was Completed by a PSM Employee, Please Enter Your E-mail.

PLEASE CLICK "SUBMIT" BUTTON AT BOTTOM OF SCREEN.

STOP: PSM USE ONLY

PSM USE ONLY: Is This a New Client?

Date of Last Physical

Additional Comments: Provide comments: