Form 54750 - Indiana - Request For Driving Ability Review Form
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REQUEST FOR DRIVING ABILITY REVIEW
BUREAU OF MOTOR VEHICLES
State Form 54750 (7-11)
CREDENTIAL PROGRAMS
BUREAU OF MOTOR VEHICLES
100 North Senate Avenue, Room N402
Indianapolis, IN 46204
INSTRUCTIONS:
1. Complete in blue or black ink.
2. Completed form must be submitted to the address above Attn: Medical Review Clerk.
Name of Driver (last, first, middle initial)
Telephone Number
(
)
Address (number and street)
City
State
ZIP Code
County
Date of Birth (mm/dd/yyyy)
Driver’s License Number
Date of License Expiration (mm/dd/yyyy)
I am requesting a driving ability review for the above named driver for the following reason:
I swear or affirm that the information I have entered on this form is correct. I understand that making a false statement may constitute the crime
of perjury.
Signatureof Requester
Printed Name
Date (mm/dd/yyyy)
Address (number and street)
City
State
ZIP Code
Affiliation
□
□
□
□
Law Enforcement: Badge Number ________
Prosecutor
BMV/C Personnel
Medical/General Power of Attorney
□
□
□
□
Rehabilitation/Medical Center
Physician
Court Appointed Guardian/Custodian
Other:_______________________
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Parent category: Legal