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